Psychological Distress in South African Healthcare Workers Early in the COVID-19 Pandemic: An Analysis of Associations and Mitigating Factors.

While the global COVID-19 pandemic has been widely acknowledged to affect the mental health of health care workers (HCWs), attention to measures that protect those on the front lines of health outbreak response has been limited. In this cross-sectional study, we examine workplace contextual factors associated with how psychological distress was experienced in a South African setting where a severe first wave was being experienced with the objective of identifying factors that can protect against HCWs experiencing negative impacts. Consistent with mounting literature on mental health effects, we found a high degree of psychological distress (57.4% above the General Health Questionnaire cut-off value) and a strong association between perceived risks associated with the presence of COVID-19 in the healthcare workplace and psychological distress (adjusted OR = 2.35, p < 0.01). Our research indicates that both training (adjusted OR 0.41, 95% CI 0.21−0.81) and the reported presence of supportive workplace relationships (adjusted OR 0.52, 95% CI 0.27−0.97) were associated with positive outcomes. This evidence that workplace resilience can be reinforced to better prepare for the onset of similar outbreaks in the future suggests that pursuit of further research into specific interventions to improve resilience is well merited.

Role of Endovascular Aortic Repair in the Treatment of Infected Aortic Aneurysms Complicated by Aortoenteric or Aortobronchial Fistulae.

BACKGROUND: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). METHODS: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. RESULTS: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). CONCLUSION: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.

Benzodiazepine therapy in psychiatric outpatients is associated with deliberate self-poisoning events at emergency departments-a population-based nested case-control study.

RATIONALE: Deliberate self-poisoning (DSP), the most common form of deliberate self-harm, is closely associated with suicide. Identifying risk factors of DSP is necessary for implementing prevention strategies. OBJECTIVES: This study aimed to evaluate the relationship between benzodiazepine (BZD) treatment in psychiatric outpatients and DSP cases at emergency departments (EDs). METHODS: We performed a retrospective nested case-control study of psychiatric patients receiving BZD therapy to evaluate the relationship between BZD use and the diagnosis of DSP at EDs using data from the nationwide Taiwan National Health Insurance Research Database. RESULTS: Regression analysis yielded an odds ratio (OR) and 95 % confidence interval (95 % CI) indicating that the use of BZDs in psychiatric outpatients was significantly associated with DSP cases at EDs (OR = 4.46, 95 % CI = 3.59-5.53). Having a history of DSP, sleep disorders, anxiety disorders, schizophrenia, depression, or bipolar disorder was associated with a DSP diagnosis at EDs (OR = 13.27, 95 % CI = 8.28-21.29; OR = 5.04, 95 % CI = 4.25-5.98; OR = 3.95, 95 % CI = 3.32-4.70; OR = 7.80, 95 % CI = 5.28-11.52; OR = 15.20, 95 % CI = 12.22-18.91; and OR = 18.48, 95 % CI = 10.13-33.7, respectively). After adjusting for potential confounders, BZD use remained significantly associated with a subsequent DSP diagnosis (adjusted OR = 2.47, 95 % CI = 1.93-3.17). Patients taking higher average cumulative BZD doses were at greater risk of DSP. CONCLUSION: Vigilant evaluation of the psychiatric status of patients prescribed with BZD therapy is critical for the prevention of DSP events at EDs.

Biphasic modulation of the mitochondrial electron transport chain in myocardial ischemia and reperfusion.

Mitochondrial electron transport chain (ETC) is the major source of reactive oxygen species during myocardial ischemia-reperfusion (I/R) injury. Ischemic defect and reperfusion-induced injury to ETC are critical in the disease pathogenesis of postischemic heart. The properties of ETC were investigated in an isolated heart model of global I/R. Rat hearts were subjected to ischemia for 30 min followed by reperfusion for 1 h. Studies of mitochondrial function indicated a biphasic modulation of electron transfer activity (ETA) and ETC protein expression during I/R. Analysis of ETAs in the isolated mitochondria indicated that complexes I, II, III, and IV activities were diminished after 30 min of ischemia but increased upon restoration of flow. Immunoblotting analysis and ultrastructural analysis with transmission electron microscopy further revealed marked downregulation of ETC in the ischemic heart and then upregulation of ETC upon reperfusion. No significant difference in the mRNA expression level of ETC was detected between ischemic and postischemic hearts. However, reperfusion-induced ETC biosynthesis in myocardium can be inhibited by cycloheximide, indicating the involvement of translational control. Immunoblotting analysis of tissue homogenates revealed a similar profile in peroxisome proliferator-activated receptor-γ coactivator-1α expression, suggesting its essential role as an upstream regulator in controlling ETC biosynthesis during I/R. Significant impairment caused by ischemic and postischemic injury was observed in the complexes I- III. Analysis of NADH ferricyanide reductase activity indicated that injury of flavoprotein subcomplex accounts for 50% decline of intact complex I activity from ischemic heart. Taken together, our findings provide a new insight into the molecular mechanism of I/R-induced mitochondrial dysfunction.

Cell transplantation for myocardial injury: a preliminary comparative study.

BACKGROUND AIMS: Cell transplantation may restore viable muscle after myocardial infarction. Because many studies have focused on one cell type, we compared the characteristics of skeletal myoblasts (SKM), bone marrow stromal/stem cells (BMSC) and smooth muscle cells (SMC) and their effects on cardiac function after myocardial injury. METHODS: In vitro cell characteristics, including proliferation, hypoxic survival and vascular endothelial cell growth factor (VEGF) expression, of SKM, BMSC and SMC were compared. An in vivo left anterior descending artery ligation rat model was used, and cells were implanted into the infarct (n = 16 per cell type). Cell survival was determined by PKH26 staining and real-time polymerase chain reaction (PCR). Cardiac function, tissue VEGF and stem cell factor (SCF) expression and vasculogenesis were evaluated. RESULTS: Although cell morphologies were distinct, in vitro proliferation was similar. In vitro studies showed that SKM had the highest hypoxic survival, whereas BMSC had the lowest hypoxic survival but the highest VEGF expression. After implantation, SKM showed the highest overall survival and in vivo SCF expression, and both SMC and SKM expressed the highest VEGF levels. Vasculogenesis was significantly (P < 0.001) improved after transplantation of each cell type. Overall, BMSC and SKM promoted the greatest improvement in cardiac function. CONCLUSIONS: SKM, BMSC and SMC expressed VEGF and SCF and promoted vasculogenesis. Although BMSC showed the greatest regenerative potential relative to cell survival and growth factor expression, the greatest improvement in cardiac function was observed with BMSC and SKM.

The efficacy of aortic stent grafts in the management of mycotic abdominal aortic aneurysm-institute case management with systemic literature comparison.

BACKGROUND: Conventional surgery (CS) for treatment of mycotic aortic aneurysm has rather high surgical morbidity and mortality rates. The use of endovascular aortic repair (EVAR) might simplify the procedure and provide a good alternative for this critical condition, but this remains to be proved. We analyzed all mycotic abdominal aortic aneurysm (AAA) cases treated by CS or EVAR in our institute and the reported cases treated by EVAR from the literature to determine the risk factors for aneurysm-related mortality and morbidity and to clarify the efficacy of the EVAR technique. METHODS AND RESULTS: All relevant literature reports of EVAR management of mycotic AAA and all cases treated in our institute, 41 cases, were included and analyzed. Of the 20 cases treated by EVAR, one had early mortality (1/20, 5%); of the remaining 21 cases that received CS, the early mortality rate was 4.8% (1/21). Patients in the CS group had a higher late mortality rate than those in the EVAR group (45% vs. 10.5%, p<0.05). However, the 24-month actual survival rate and actuarial aneurysm-related event-free rate were 83.9+/-8.6% and 78.3+/-9.7%, respectively, for the EVAR group and did not significantly differ from the CS group (70.4+/-10.2% and 80.1+/-8.9%). The significant predictors for aneurysm-related mortality and morbidity were age, Salmonella species infection, and leukocytosis, and possibly aortoenteric fistula and shock, but not the EVAR or CS procedures themselves. CONCLUSION: Compared with CS, EVAR might be an alternative strategy for managing mycotic AAAs.

Preservation of mitochondrial function with cardiopulmonary resuscitation in prolonged cardiac arrest in rats.

During cardiac arrest (CA), myocardial perfusion is solely dependent on cardiopulmonary resuscitation (CPR) although closed-chest compressions only provide about 10-20% of normal myocardial perfusion. The study was conducted in a whole animal CPR model to determine whether CPR-generated oxygen delivery preserves or worsens mitochondrial function. Male Sprague-Dawley rats (400-450 g) were randomly divided into four groups: (1) BL (instrumentation only, no cardiac arrest), (2) CA(15) (15 min cardiac arrest without CPR), (3) CA(25) (25 min cardiac arrest without CPR) and (4) CPR (15 min cardiac arrest, followed by 10 min CPR). The differences between groups were evaluated by measuring mitochondrial respiration, electron transport chain (ETC) complex activities and mitochondrial ultrastructure by transmission electron microscopy (TEM). The CA(25) group had the greatest impairment of mitochondrial respiration and ETC complex activities (I-III). In contrast, the CPR group was not different from the CA(15) group regarding all measures of mitochondrial function. Complex I was more susceptible to ischemic injury than the other complexes and was the major determinant of mitochondrial dysfunction. Observations of mitochondrial ultrastructure by TEM were compatible with the biochemical results. The findings suggest that, despite low blood flow and oxygen delivery, CPR is able to preserve heart mitochondrial function and viability during ongoing global ischemia. Preservation of complex I activity and mitochondrial function during cardiac arrest may be an important mechanism underlying the beneficial effects of CPR which have been shown in clinical studies.

Comparative effects of the formulation of glyphosate-surfactant herbicides on hemodynamics in swine.

INTRODUCTION: Most of the glyphosate-surfactant herbicides (GlySH) are formulated commercial products containing isopropylamine (IPA) salt of glyphosate (IPAG), variable amount of a surfactant, and water. Although glyphosate is only slightly toxic to rats, ingestion of GlySH may lead to severe effects, including death, in humans. We conducted a study to evaluate the cardiovascular effects of the components of GlySH. METHODS: We used five groups of male piglets, each receiving infusion of normal saline (control), glyphosate in NaOH base, IPA, IPAG, and polyoxyethyleneamine (POEA), respectively. We chose concentrations that are similar to those in the commonly used GlySH (41% of IPAG and 15% surfactant). RESULTS: We found that IPAG reduced the mean arterial blood pressure (MABP) and left-ventricular stroke work index (LVSWI) during the infusion, but both recovered gradually. It also decreased the cardiac index but increased the pulmonary capillary wedge pressure, central venous pressure (CVP), and mean pulmonary arterial pressure (MPAP). POEA infusion reduced the cardiac index and LVSWI, but not the MABP. It also increased the pulmonary capillary wedge pressure, CVP, MPAP, and pulmonary vascular resistance index. IPA increased the MABP, which was higher than those in the control, IPAG, and POEA groups. Glyphosate in NaOH base infusion did not affect the hemodynamics but slightly reduced the blood pH and base excess (BE) values. POEA and IPAG also resulted in metabolic acidosis, with lactate formation and decreased BE values. CONCLUSION: We conclude that both POEA and IPAG infusion affected hemodynamics and resulted in death in piglets, whereas glyphosate (NaOH base) had no similar effects.

The radical trap 5,5-dimethyl-1-pyrroline N-oxide exerts dose-dependent protection against myocardial ischemia-reperfusion injury through preservation of mitochondrial electron transport.

Free radicals are important mediators of myocardial ischemia-reperfusion injury. Nitrone spin traps have been shown to scavenge free radicals. The cardioprotective effect of the spin trap, 5,5-dimethyl-1-pyrroline N-oxide (DMPO), was investigated in an isolated heart model of global ischemia and reperfusion. Rat hearts were perfused and subjected to global ischemia for 30 min followed by reperfusion with four treatment groups of varying DMPO concentration (0.5-10 mM) administered before induction of ischemia. DMPO treatment improved the recovery of left ventricular (LV) function and coronary flow over the 30-min period of reperfusion compared with untreated hearts. Enhanced recovery was observed for all doses studied but was highest with 1 mM treatment with 2.4-fold higher recovery of LV developed pressure and 37% reduction in infarct size. Superoxide was measured by tissue fluorometry using the O(2)* probe hydroethidine. Hearts treated with 1 mM DMPO showed a significant reduction in O(2)* production compared with control hearts both over the first 5 min of ischemia and upon reperfusion after 30 min of global ischemia. Studies of mitochondrial function demonstrated that 1 mM DMPO increased the recovery of function of complexes I, II/III, and IV after 30 min of reperfusion. Immunoblotting with antibodies against complexes I, II, and IV further revealed marked up-regulation of mitochondrial proteins, suggesting that DMPO prevents their ischemic degradation via scavenging oxygen radicals generated during ischemia/reperfusion. Thus, DMPO functions as a protective agent against ischemic and postischemic injury via radical scavenging, conferring robust dose-dependent protection with salvage of mitochondrial function and redox homeostasis.

Bacteroides fragilis aortic arch pseudoaneurysm: case report with review.

We present a case of 58-year-old woman with underlying diabetes mellitus, hepatitis C virus-related liver cirrhosis, and total hysterectomy for uterine myoma 11 moths ago, who was diagnosed ruptured aortic arch mycotic pseudoaneurysm after a certain period of survey for her unknown fever cause. After emergent surgery with prosthetic graft interposition, all her blood cultures and tissue cultures revealed pathogen with Bacteroides fragilis. Although mycotic aneurysms have been well described in literatures, an aneurysm infected solely with Bacteroides fragilis is unusual, with only eight similar cases in the literature. Here we reported the only female case with her specific clinical and management course and summarized all reported cases of mycotic aneurysm caused by Bacteroides fragilis to clarify their conditions and treatments, alert the difficulty in diagnosis, and importance of highly suspicious.

Presentations of patients of poisoning and predictors of poisoning-related fatality: findings from a hospital-based prospective study.

BACKGROUND: Poisoning is a significant public health problem worldwide and is one of the most common reasons for visiting emergency departments (EDs), but factors that help to predict overall poisoning-related fatality have rarely been elucidated. Using 1512 subjects from a hospital-based study, we sought to describe the demographic and clinical characteristics of poisoning patients and to identify predictors for poisoning-related fatality. METHODS: Between January 2001 and December 2002 we prospectively recruited poisoning patients through the EDs of two medical centers in southwest Taiwan. Interviews were conducted with patients within 24 hours after admission to collect relevant information. We made comparisons between survival and fatality cases, and used logistic regressions to identify predictors of fatality. RESULTS: A total of 1512 poisoning cases were recorded at the EDs during the study period, corresponding to an average of 4.2 poisonings per 1000 ED visits. These cases involved 828 women and 684 men with a mean age of 38.8 years, although most patients were between 19 and 50 years old (66.8%), and 29.4% were 19 to 30 years. Drugs were the dominant poisoning agents involved (49.9%), followed by pesticides (14.5%). Of the 1512 patients, 63 fatalities (4.2%) occurred. Paraquat exposure was associated with an extremely high fatality rate (72.1%). The significant predictors for fatality included age over 61 years, insufficient respiration, shock status, abnormal heart rate, abnormal body temperature, suicidal intent and paraquat exposure. CONCLUSION: In addition to well-recognized risk factors for fatality in clinical settings, such as old age and abnormal vital signs, we found that suicidal intent and ingestion of paraquat were significant predictors of poisoning-related fatality. Identification of these predictors may help risk stratification and the development of preventive interventions.

Outcome after endovascular stent graft treatment for mycotic aortic aneurysm: a systematic review.

BACKGROUND: Surgical treatment for mycotic aortic aneurysms is not optimal. Even with a large excision, extensive debridement, in situ or extra-anatomical reconstruction, and with or without lifelong antibiotic treatment, mycotic aneurysms still carry very high mortality and morbidity. The use of endovascular aneurysm repair (EVAR) for mycotic aortic aneurysms simplifies the procedure and provides a good alternative for this critical condition. However, the question remains: if EVAR is placed in an infected bed, what is the outcome of the infection? Does it heal, become aggravated, or even cause a disastrous aortic rupture? In this study, we tried to clarify the risk factors for such an adverse response. METHODS: A literature review was undertaken by using MEDLINE. All relevant reports on endoluminal management of mycotic aortic aneurysms were included. Logistic regressions were applied to identify predictors of persistent infection. RESULTS: A total of 48 cases from 22 reports were included. The life-table analysis showed that the 30-day survival rate was 89.6% +/- 4.4%, and the 2-year survival rate was 82.2% +/- 5.8%. By univariate analysis, age 65 years or older, rupture of the aneurysm (including those with aortoenteric fistula and aortobronchial fistula), and fever at the time of operation were identified as significant predictors of persistent infection, and preoperative use of antibiotics for longer than 1 week and an adjunct procedure combined with EVAR were identified as significant protective factors for persistent infection. However, by multivariate logistic regression analysis, the only significant independent predictors identified were rupture of aneurysm and fever. CONCLUSIONS: EVAR seems a possible alternative method for treating mycotic aortic aneurysms. Identification of the risk factors for persistent infection may help to decrease surgical morbidity and mortality. EVAR could be used as a temporary measure; however, a definite surgical treatment should be considered for patients present with aneurysm rupture or fever.

Efficacy and tolerability of the switch from a branded to a generic warfarin sodium product: an observer-blinded, randomized, crossover study.

BACKGROUND: Anticoagulation is an essential part of the management of numerous cardiovascular conditions. Although warfarin sodium has been in clinical use for >40 years, only 1 proprietary warfarin preparation was in use for long-term anticoagulation in Taiwan until 2001, when the Taiwan Food and Drug Administration approved a new generic formulation. OBJECTIVE: This study evaluated the efficacy and tolerability of switching from an established dose of the branded warfarin sodium product (in mg/wk) to the same dose of the generic product. METHODS: This was a randomized, observer-blinded,crossover study in Taiwanese patients who received a mechanical heart valve to replace an original valve or a previously implanted mechanical valve from March 2003 to August 2004 and had received branded warfarin therapy for >/=2 months postoperatively, with a mean baseline international normalized ratio (INR) in the range from 1.7 to 3.0 in the 8- to 12-week run-in period. Patients were randomized to 1 of 2 treatment sequences, each involving three 28-day periods: the generic product for 1 period followed by the branded product for 2 periods, or the branded product for 1 period followed by the generic product for 2 periods. Prothrombin time and INR were measured, and anticoagulant activity was compared. At each visit, treatment-emergent adverse events were recorded and evaluated by the blinded observer, an internal medicine physician who was not involved in patients' care. RESULTS: Thirty-five patients were enrolled (25 men, 10 women; mean age, 52.4 years [range, 34.5-74.4 years]). All but 2 of the patients had received a replacement for a natural heart valve. Thirty-four patients (16 who received the generic product initially, 18 who received the branded product initially) completed the study without a dose change and were >/=75% compliant with therapy. There was no difference in pooled mean (SE) INR between the 2 products (2.28 [0.06] and 2.27 [0.06], respectively). The 90% CI for the difference was 96.4 to 104.9, well within the range for bioequivalence (80-120). There were no differences in the adverse-event profiles of the 2 formulations. CONCLUSIONS: No therapeutic inequivalence was demonstrated in this small, single-blind study, suggesting that the generic and branded warfarin products studied were equally effective in maintaining anticoagulation in patients with mechanical prosthetic heart valves. The 2 products had similar safety profiles.

Clinical significance and mechanism of gas formation of pyogenic liver abscess due to Klebsiella pneumoniae.

We enrolled 22 patients with gas-forming pyogenic liver abscess in a study to assess the mechanism of gas formation. Klebsiella pneumoniae was cultured from specimens from all patients. Gas and pus samples from abscesses revealed four major components: nitrogen, oxygen, carbon dioxide, and hydrogen; this implicates mixed acid fermentation of glucose as the mechanism of gas formation.

Clinical manifestations and complications of rickettsiosis in southern Taiwan.

BACKGROUND AND PURPOSE: Taiwan is an endemic area for scrub typhus. Recent increases have been noted in two other infectious diseases caused by obligate intracellular organisms, Q fever and murine typhus. These diseases usually present as an acute febrile illness with non-specific symptoms and are difficult to distinguish. This study describes the clinical manifestations and complications of cases of rickettsial infections treated at a medical center in southern Taiwan. METHODS: Serum samples from patients with acute febrile illness with or without shock, but without a clinical diagnosis of localized bacterial infection after a preliminary work-up, were collected for serologic study. Medical records of cases with serologic evidence of infection were reviewed and their clinical manifestations were analyzed. RESULTS: From October 1992 to July 2000, 51 serologically diagnosed cases of rickettsiosis were studied. Q fever predominated (28 cases). All cases of acute Q fever presented with hepatitis during the course of the illness and more than half (54%) reported an animal contact history. Most patients with Q fever (96%) and murine typhus (86%) were male, Serious complications, especially pneumonitis, occurred more frequently with scrub typhus than with acute Q fever. Spontaneous remission frequently occurred with acute Q fever. Administration of tetracycline or its analogues usually resulted in defervescence by the third day of treatment of scrub typhus. CONCLUSIONS: In our study, serious complications including pneumonitis, meningitis/meningoencephalitis, shock, acute renal failure, and disseminated intravascular coagulation were not uncommon in patients with scrub typhus. Physicians should include scrub typhus in the differential diagnosis of suspected cases of community-acquired febrile illness with multiple organ dysfunction in this endemic area. As Q fever is an emerging infectious disease in southern Taiwan, further large-scale epidemiologic surveillance and clinical data are needed.