Restructuring ENT out-patient services during the coronavirus disease 2019 pandemic - an iterative approach

BACKGROUND

Coronavirus disease 2019 has demanded enormous adjustments to National Health Service provisions. Non-urgent out-patient work was initially postponed or performed virtually, but is now being re-established. In ENT surgery, aerosol-generating procedures pose a particular challenge in out-patient settings.

OBJECTIVE

A rapid restructuring of ENT out-patient services is required, to safely accommodate aerosol-generating procedures and increase in-person attendances, whilst coronavirus disease 2019 persists.

METHODS

Data were collected prospectively over four consecutive cycles. Two surveys were conducted. Results were analysed and disseminated, with recommendations for service restructuring implemented at cycle end-points.

RESULTS

Out-patient activity increased four-fold, associated with a significant rise in aerosol-generating procedures during the study period. Mean aerosol-generating procedure duration dropped weekly, implying a learning curve. Service restructuring occurred at cycle end-points.

CONCLUSION

Iterative data gathering, results analysis and outcome dissemination enabled a swift, data-driven approach to the restructuring of ENT out-patient services. Patient and staff safety was ensured, whilst out-patient capacity was optimised.

Drug therapy for nocturnal enuresis. Current treatment recommendations

It is estimated that enuresis occurs in 5 to 7 million children in the United States. The treatment approach for enuresis is controversial, in large part due to a lack of consensus as to the exact cause of enuresis. Several factors either alone or together may contribute to this syndrome. In addition, there is strong evidence of a genetic component to enuresis. Pharmacotherapy continues to be the preferred treatment for both physicians and families. The most widely used drugs include antidepressants, anticholinergics, and desmopressin. The tricyclic antidepressant imipramine has been used extensively since the 1960s. The exact mechanism of action in enuresis is unknown although it appears to be related to the anticholinergic and antispasmodic effects of the drug. The most common adverse effects reported with imipramine include personality changes, insomnia, anorexia and anxiety. There has been renewed interest in antidiuretic treatment of enuresis. Researchers have found that enuretic children do not have the ability to reduce urine volume at night or concentrate the urine they produce during the night. Clinical trials with desmopressin administered by nasal inhalation report a marked reduction in enuretic episodes. Adverse effects were limited to nasal complaints, rhinitis, or epistaxis. Additional long term studies are needed to delineate desmopressin's role in therapy. Although the number of options for treatment of enuresis is expanding, criteria to predict patient response need to be defined.

Cytokeratin reorganization induced by adenosine diphosphate in kidney epithelial cells

Exogenous adenosine diphosphate (ADP), the most potent mitogen for nontransformed African green monkey kidney epithelial cells of the BSC-1 line, rapidly alters the appearance of the cell monolayer. Examination of the cells with indirect immunofluorescence using monoclonal antibodies reveals a considerable reorganization of cytokeratin filaments without a major change in the pattern of microtubules or microfilaments. In untreated confluent cells, cytokeratin filaments are predominantly confined to a star-like spot in the perinuclear area, but these can be seen to begin to spread within 2 min after addition of ADP. The effect is particularly notable using anti-cytokeratin 8 antibodies. At 6 h this process is complete and produces a well-developed filamentous network throughout the cell. By 12 h, the network appears to collapse, so that the filaments again form a spot in the perinuclear area, a process that is complete by 24 h. Immunoblotting of total cellular proteins reveals no apparent alterations in the amounts of several species of cytokeratins, including cytokeratin 8 and 18, at 3 or 24 h after exposure to ADP. Other purine and pyrimidine nucleotides which do not stimulate DNA synthesis in these cells fail to alter cytokeratin organization, and there is no apparent alteration in the distribution of vimentin, another intermediate filament protein. The rapid ADP-induced cytokeratin reorganization appears to coincide with the induction of early growth-response gene transcription in these cells and may be correlated with the capacity of ADP to subsequently initiate DNA synthesis. This dramatic and reversible cytokeratin reorganization immediately after exposure to ADP may be an important step in the mitogenic signal transduction pathway.

Enalapril: a well-tolerated and efficacious agent for the paediatric hypertensive patient

Enalapril, either alone or with a diuretic, was administered to 14 children with various renal diseases and hypertension. Five were transplant recipients on immunosuppressive agents. No adverse clinical or laboratory experiences were encountered. Renal function improved in seven children. Normal blood pressure for age was achieved in all 14 children. However, eight children required the addition of a diuretic. In four children blood pressure remained normal despite a reduction in the dose of enalapril. Enalapril was efficacious as a once per day agent. Concomitant ingestion of food did not attenuate the blood pressure-lowering effect of enalapril.