Epidemiology of neonatal pneumothorax developed spontaneously and during respiratory supports in neonatal intensive care units.

BACKGROUND: Information on incidence and risk factors associated with different types of neonatal pneumothorax were lacking globally. OBJECTIVES: To determine incidences of pneumothorax developed spontaneously and during different modes of respiratory support, and risk factors associated with each type of pneumothorax. STUDY DESIGN: Retrospective observational study of neonates in the Malaysian National Neonatal Registry. SETTING: 44 Malaysian neonatal intensive care units (NICUs). PARTICIPANTS: All neonates born in 2015-2020 and admitted to NICUs. RESULTS: Pneumothorax developed in 3265 neonates: 37.5% occurred spontaneously, 62.5% during respiratory support. The incidence of all types of pneumothorax was 1.75 per 1000 livebirths, and of spontaneous pneumothorax was 0.58 per 1000 livebirths. Pneumothorax developed in 0.6% (450/70512) of neonates during continuous positive air way pressure therapy (nCPAPt), 1.8% (990/54994) of neonates during conventional mechanical ventilation (CMV), and 7.0% (599/8557) of neonates during high frequency ventilation (HFV). Term neonates had significantly higher pneumothorax rate than preterms (p<0.001). Multiple logistic regression analyses show that exposure to intermittent positive pressure ventilation and chest compression at birth were significant independent factors associated with increased risk of spontaneous pneumothorax and CMV, and persistent pulmonary hypertension was associated with increased risk of spontaneous pneumothorax and pneumothorax during CMV and HFV. CONCLUSIONS: The most common type of pneumothorax was spontaneous in-onset. Neonates on HFV had the highest and those on nCPAPt the lowest rate of pneumothorax. Improving training of resuscitation techniques at birth and strategies of use of invasive modes of respiratory support may reduce incidences of all types of pneumothorax.

Early-onset sepsis in Malaysian neonatal intensive care units.

OBJECTIVES: To determine the incidence, causative pathogens, morbidities, mortality, and risk factors associated with blood culture-positive early-onset sepsis (EOS, ≤72 hours of age) in symptomatic neonates admitted to the neonatal intensive care units (NICUs) of a middle-income country. STUDY DESIGN: Retrospective cohort study using data submitted prospectively to the Malaysian National Neonatal Registry (MNNR). SETTING: 44 Malaysian NICUs. PARTICIPANTS: All neonates born in 2015- 2020. RESULTS: EOS was reported in 991 neonates. The annual incidence of EOS increased from 0.46 to 0.49/1000 livebirths over the six years. The most common pathogen was Streptococcus agalactiae or Group B haemolytic streptococcus (GBS) (n=388, 39.2%), followed by Escherichia coli (E. coli) (n=80, 8.1%), Klebsiella spp (n=73, 7.4%), coagulase negative staphylococcus (CONS) (n=73, 7.4%), Pseudomonas spp (n=44, 4.4%) and methicillin-sensitive Staphylococcus aureus (n=34, 3.4%). The incidence of EOS due to GBS increased from 0.17 to 0.22/1000 livebirths. Morbidities and mortality were higher in those with EOS than without EOS. Multiple logistic regression analysis showed that Indian ethnic group, chorioamnionitis, gestation≥37weeks, female, spontaneous vaginal delivery, instrumental delivery, and surfactant therapy were significantly associated with increased risk of EOS due to GBS. Four factors were significantly associated with increased risk of non-GBS EOS (outborns, birthweight lt;1000 g, vaginal delivery, and surfactant therapy). Early continuous positive airway pressure was associated with significantly lower risk of EOS. CONCLUSION: The incidence of EOS showed an increasing trend in Malaysian NICUs. GBS was the most common causative pathogen. Several modifiable risk factors associated with EOS have been identified.

Linguistic validation of the simplified Chinese version of the US National Cancer Institute's patient-reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE™).

BACKGROUND: The aim of this study was to translate and linguistically validate the U.S. National Cancer Institute's Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) into Simplified Chinese for use in Singapore. METHODS: All 124 items of the English source PRO-CTCAE item library were translated into Simplified Chinese using internationally established translation procedures. Two rounds of cognitive interviews were conducted with 96 cancer patients undergoing adjuvant treatment to determine if the translations adequately captured the PRO-CTCAE source concepts, and to evaluate comprehension, clarity and ease of judgement. Interview probes addressed the 78 PRO-CTCAE symptom terms (e.g. fatigue), as well as the attributes (e.g. severity), response choices, and phrasing of 'at its worst'. Items that met the a priori threshold of ≥20% of participants with comprehension difficulties were considered for rephrasing and retesting. Items where < 20% of the sample experienced comprehension difficulties were also considered for rephrasing if better phrasing options were available. RESULTS: A majority of PRO-CTCAE-Simplified Chinese items were well comprehended by participants in Round 1. One item posed difficulties in ≥20% and was revised. Two items presented difficulties in < 20% but were revised as there were preferred alternative phrasings. Twenty-four items presented difficulties in < 10% of respondents. Of these, eleven items were revised to an alternative preferred phrasing, four items were revised to include synonyms. Revised items were tested in Round 2 and demonstrated satisfactory comprehension. CONCLUSIONS: PRO-CTCAE-Simplified Chinese has been successfully developed and linguistically validated in a sample of cancer patients residing in Singapore.

Flash glucose monitoring: Impact on markers of glycaemic control and patient-reported outcomes in individuals with type 1 diabetes mellitus in the real-world setting.

AIMS: We aimed to evaluate both glycaemic parameters and patient-reported outcomes in patients prescribed FGM based on the local criteria at our institution. METHODS: This retrospective observational study included patients aged > 18 years with a diagnosis of type 1 diabetes mellitus (T1DM) who were prescribed FreeStyle Libre FGM (n = 90). Quantitative data on glycaemic parameters was collected pre- and post-initiation of FGM in addition to patient-reported outcome measures (PROMs). The primary outcome was change in pre- and post-FGM levels of glycosylated haemoglobin (HbA1C). RESULTS: There was a mean reduction in HbA1c of -7.29 ±â€¯10.76 mmol/mol (p < 0.001, CI95% 4.94-9.64) sustained to the latest reading. There was also a mean reduction in the number of hypoglycaemic episodes per week of 3.20 (percentage reduction 51.86%, p < 0.001, CI95% 1.64-4.77). A significant improvement in quality of life scores was noted in all five domains of the abbreviated DDS between before and after starting FGM (p < 0.001). Key themes highlighted in inductive content analysis include 'life-changing', 'positive experience', and 'convenient'. CONCLUSION: Flash glucose monitoring is associated with significant improvement in HbA1c to a mean follow-up of 4.6 months. Additionally, patients reported positive experiences of FGM with significant improvement in all aspects of a focussed Diabetes Distress Scale.

A coupled chlorinase-fluorinase system with a high efficiency of trans-halogenation and a shared substrate tolerance.

Enzymatic trans-halogenation enables radiolabeling under mild and aqueous conditions, but rapid reactions are desired. We developed a coupled chlorinase-fluorinase system for rapid trans-halogenation. Notably, the chlorinase shares a substrate tolerance with the fluorinase, enabling these two enzymes to cooperatively produce 5'-fluorodeoxy-2-ethynyladenosine (5'-FDEA) in up to 91.6% yield in 1 h.

Association between demographics and resilience - a cross-sectional study among nurses in Singapore.

AIM: To give an overview of the level of resilience among nurses in Singapore and to examine associations between various demographics variables and resilience level. BACKGROUND: The World Health Organization reported a global needs-based shortage of over 9 million nurses and midwives in 2013. Building resilience among nurses has been postulated as one of the ways to support and retain nurses in the profession. METHOD: A self-reported questionnaire consisting of questions on demographics and the Connor-Davidson Resilience Scale CD-RISC 10 was used. RESULTS: Univariate analysis identified marital status, age group, years of experience in nursing, highest education qualification and job grade to have significant associations with resilience. During multivariate analysis, only marital status, age group, highest educational qualification and job grade remained significant. A strong association was found between highest educational qualification and resilience level; nurses with bachelor's or postgraduate degree were about three times more likely than nurses with only a general nursing certificate to be of moderate/high resilience. CONCLUSION: The experience of life events (as exemplified by marital status, age and working experience) was associated with higher resilience levels. IMPLICATIONS FOR NURSING POLICY: There is a need for healthcare organizations and nurse leaders to develop programmes focusing on building resilience among younger and less experienced nurses. Nurses should also be supported in their pursuits for higher education, which will in turn lead to higher resilience, and consequently, retention of nurses within the profession and institution.

Probing the molecular determinants of fluorinase specificity.

Molecular determinants of FlA1 fluorinase specificity were probed using 5'-chloro-5'-deoxyadenosine (5'-ClDA) analogs as substrates and FlA1 active site mutants. Modifications at F213 or A279 residues are beneficial towards these modified substrates, including 5'-chloro-5'-deoxy-2-ethynyladenosine, ClDEA (>10-fold activity improvement), and conferred novel activity towards substrates not readily accepted by wild-type FlA1.

Diagnostic accuracy of 3-T magnetic resonance imaging with 3D T1 VIBE versus computer tomography in pars stress fracture of the lumbar spine.

OBJECTIVE: To compare the diagnostic accuracy of 3-T magnetic resonance imaging (MRI) with thin-slice 3D T1 VIBE sequence to 128-slice computer tomography (CT) in pars stress fractures of the lumbar spine. MATERIALS AND METHODS: 3-T MRI and CT of 24 patients involving 70 pars interarticularis were retrospectively reviewed by four blinded radiologists. The fracture morphology (complete, incomplete, or normal) was assessed on MRI and CT at different time points. Pars interarticularis bone marrow edema (present or absent) was also evaluated on MRI. RESULTS: In total, 14 complete fractures, 31 incomplete fractures and 25 normal pars were detected by CT. Bone marrow edema was seen in seven of the complete and 25 of the incomplete fractures. The overall sensitivity, specificity and accuracy of MRI in detecting fractures (complete and incomplete) were 97.7, 92.3, and 95.7 %, respectively. MRI was 100 % accurate in detecting complete fractures. For incomplete fractures, the sensitivity, specificity, and accuracy of MRI were 96.7, 92.0, and 94.6 %, respectively. CONCLUSIONS: 3-T MRI with thin-slice 3D T1 VIBE is 100 % accurate in diagnosing complete pars fractures and has excellent diagnostic ability in the detection and characterization of incomplete pars stress fractures compared to CT. MRI has the added advantages of detecting bone marrow edema and does not employ ionizing radiation.

Reliability of acute illness dihydrorhodamine-123 testing for chronic granulomatous disease.

BACKGROUND: Dihydrorhodamine (DHR) flow cytometric analysis is used to evaluate granulocyte oxidative bursts and is the test of choice for the diagnosis of chronic granulomatous disease (CGD). We present the clinical and DHR test profiles of five subjects assessed during and after acute illness. METHODS: This was a retrospective report of the findings of five out of a total of one hundred and seventeen patients, whose blood was sent to the laboratory for dihydrorhodamine-123 flow cytometry testing between January 2005 and December 2010. Using whole blood technique and stimulation using phorbol myristate acetate, the results of DHR were expressed as stimulation index and coefficient of variation of histograms of stimulated cells and compared with healthy controls. DHR tests were repeated when the patients had recovered and were clinically well. RESULTS: These five patients showed abnormal DHR test results during their acute illness, with a stimulation index (SI) lower (p = 0.009) and coefficient of variation (CV) higher (p = 0.009) than controls. The DHR profiles repeated when patients had recovered showed normalization of tests with no significant difference for SI (p = 0.602) and CV (p = 0.917) compared to controls. Wilcoxon Signed Rank tests showed a significant improvement in SI (p = 0.043) and CV (p = 0.043) upon recovery. On follow up, all five patients were well, with no further severe or atypical infections. CONCLUSIONS: DHR may be transiently abnormal during acute illness, and may therefore not be reliable when assessed during an acute illness. If these subjects had CGD, it would be of a hypomorphic variant that has not previously been described.

Assessment of the efficacy of bio-absorbable oxidized regenerated cellulose for prevention of post-operative pericardial adhesion in the rabbit model.

Pericardial adhesions complicate re-operative cardiac surgery and several attempts have been made to reduce adhesion formation. The efficacy of bio-absorbable oxidized regenerated cellulose in preventing post-operative pericardial adhesions was evaluated in the present study. Forty New Zealand white rabbits were divided into four groups of 10. In all rabbits an area of pericardium (2 x 2 cm) was excised. The wound was left open in groups 1 and 2 but replaced with bio-absorbable oxidized regenerated cellulose in groups 3 and 4. Rabbits in groups 1 and 3 were killed 3 weeks after surgery and those in groups 2 and 4 were killed at 6 weeks. Groups 1 and 2 showed more severe pericardial adhesions, more fibrous reaction and increased visibility of coronary vessels than groups 3 and 4, although there was no difference in inflammation. Light microscopy showed a mesothelium-like cell layer in groups 3 and 4. It is concluded that bio-absorbable oxidized regenerated cellulose may be suitable in patients receiving staged cardiac surgery and in those with a high probability of re-operation.

Potential therapeutic effects of exercise to the brain.

Exercise is a well-recognized facet of modern living; however, the threat of sedentary lifestyle is ever increasing with the arrival of the technological period. Although the beneficial effects of exercise to the health and function of the brain have been accepted by the scientific and medical community, much remains to be achieved to understand its mechanisms of action. With the advent of modern investigative tools, several more key molecular and cellular players have been implicated in the above process. Such include the family of neurotrophins (e.g. NGF and BDNF) and their receptors, some pro-inflammatory cytokines (L-1beta, IL-6, TNF-alpha, IFN-gamma), microglia and astrocytes, and the cholinergic neuronal cells in the forebrain. While experiments based on the voluntary exercise paradigm has been the preferred approach to studying the brain, less is known about the forced paradigm. We will discuss in this review how molecular players may feature differently in the context of exercise and more importantly how their actions converged to impact the structure, and function (learning and memory) of the CNS.

Cytokine changes in the horizontal diagonal band of Broca in the septum after running and stroke: a correlation to glial activation.

The relationship between running, glial cell activation and pro-inflammatory cytokines was studied in the context of neuroprotection against ischemic stroke induced by middle cerebral artery occlusion (MCAO). This was investigated in four groups of rats, namely, (1) nonrunner, (2) runner after 12 weeks of treadmill running, (3) nonrunner with MCAO and (4) runner with MCAO. The horizontal diagonal band of Broca (HDB) in the septum was scrutinized for qualitative cum quantitative changes in the microglia and astrocytes. Reverse transcription-polymerase chain reaction and immunoblot work were carried out in the forebrain homogenate to determine, respectively, the gene and protein expression of several pro-inflammatory cytokines. Our results indicated that the runner exhibited less immunoreactivity and reduced numbers of glial cells within the HDB compared with the nonrunner. Interestingly, the mRNA and protein levels of tumor necrosis factor-alpha, interleukin (IL)-1beta, IL-6 and interferon-gamma, were significantly downregulated in the runner. Our data also suggest albeit with some inconsistency that the runner/MCAO rats had benefited from running. These observations suggest that running can result in changes to the microenvironment, in which the microglia and astrocytes exist in a state of quiescence concomitant with a reduced expression of pro-inflammatory cytokines, that may lead to beneficial effects seen in ischemic stroke induced by MCAO.

Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton.

Osteoradionecrosis (ORN) of the craniomaxillofacial skeleton is a serious and debilitating complication that can occur following radiation therapy in the head and neck. Patients require effective treatment, which eradicates diseased tissue and restores function with minimal additional morbidity in a single stage, a requirement fulfilled in many cases by free tissue transfer. In a 6-year period from 1994 to 1999, 21 patients with ORN were treated by wide resection and free-flap reconstruction. The median interval between radiation therapy and ORN was 4 years (range: 1-33 years). The median radiation dose was 6000cGy. The affected areas were the mandible (15 patients), the temporal bone (three patients), the maxilla (one patient), the cervical vertebrae (one patient) and the frontal bone (one patient). Clinical symptoms included pain, ulceration, a persistent draining fistula, exposure of bone or hardware, and pathological fracture or non-union of bone. Six patients had had previous unsuccessful attempts at conservative surgical resection. Ten patients had preoperative hyperbaric oxygen (HBO) therapy. A number of different flaps were used for reconstruction in these patients. These included free fibula flaps (13 patients), iliac crest flaps (two patients), scapula flaps (three patients) and rectus abdominis flaps (three patients). All patients achieved relief from their presenting symptoms and primary bone or wound healing. One flap (4.8%) was lost. This was successfully reconstructed in a subsequent procedure. There were three flap re-explorations, two for arterial thrombosis and one for venous thrombosis. Conservative measures, such as limited debridement and HBO therapy, may be effective in preventing the progression of ORN. However, they fail to eradicate established ORN, which requires radical surgical resection followed by functional reconstruction with well-vascularised tissue.

Neuroprotection associated with running: is it a result of increased endogenous neurotrophic factors?

The possible neuroprotective effect of physical exercise was investigated in rats after middle cerebral artery occlusion (MCAO), a focal stroke model. It was found that physical exercise in the form of a 12-week treadmill running programme reduced the volume of infarction caused by MCAO. At the molecular level, reverse transcription polymerase chain reaction revealed that the runner had increased gene expression for nerve growth factor (NGF) over the nonrunner with or without MCAO. Expression of the NGF receptors, p75, was increased only in the absence of MCAO. In addition, runners showed a significantly higher number of cholinergic neurons, which constitutively expressed p75, in the horizontal diagonal band of Broca. The present findings suggest that neuroprotection after physical exercise may be a result of an increase in an endogenous neurotrophic factor nerve growth factor and the proliferation of its receptive cholinergic neurons.

Massive bleeding from a Dieulafoy-like lesion of the rectum in a burns patient.

Gastrointestinal haemorrhage is a rare but well-recognised complication of extensive burns, the site of haemorrhage usually being in the upper gastrointestinal tract. The case of an 18-year old female patient who developed sudden massive rectal bleeding 1 month after suffering 45% body surface area burns is presented. The source of the haemorrhage was a Dieulafoy-type lesion at the anorectal junction associated with mucosal ulceration, a cause of bleeding not previously described in a patient with major burns. Angiographic embolisation failed to control the haemorrhage and surgical arrest was required, following which the patient made a complete recovery with no recurrence of bleeding. Haemorrhage from the lower gastrointestinal tract is rarely associated with major burns but may be significant when it occurs. The aetiology is unclear but sepsis, mucosal ischaemia and ulceration may be implicated.

Induction of nuclear factor-kappaB in nucleus accumbens by chronic cocaine administration.

DeltaFosB is a Fos family transcription factor that is induced by chronic exposure to cocaine and other drugs of abuse in the nucleus accumbens and related striatal regions, brain regions that are important for the behavioral effects of these drugs. To better understand the mechanisms by which DeltaFosB contributes to the effects of chronic drug treatment, we used DNA microarray analysis to identify genes that are regulated in the nucleus accumbens upon DeltaFosB expression in inducible bitransgenic mice. One of the most highly regulated genes was that encoding a subunit of another transcription factor, nuclear factor-kappaB (NF-kappaB). Subsequent experiments confirmed the induction of NF-kappaB in the nucleus accumbens of mice overexpressing DeltaFosB as well as in wild-type mice treated chronically, but not acutely, with cocaine. These results establish NF-kappaB as a putative target for DeltaFosB and implicate NF-kappaB signaling pathways in the long-term adaptations of nucleus accumbens neurons to cocaine.

Evaluating the role of alternative therapy in burn wound management: randomized trial comparing moist exposed burn ointment with conventional methods in the management of patients with second-degree burns.

CONTEXT: Moist exposed burn ointment (MEBO), from China, has been said to revolutionize burn management. OBJECTIVE: Our study was conducted to compare MEBO with conventional management (C) with respect to the rate of wound healing, antibacterial and analgesic effect, and hospital costs. DESIGN: This is a prospective, randomized, controlled clinical trial conducted between 1 March 1997 and 24 October 1998. SETTING: The trial was conducted in a specialized burn facility located in a tertiary referral hospital in a developed and industrialized island-state in Southeast Asia. PATIENTS: We randomly assigned 115 consecutive patients between the ages of 12 and 80 who had partial-thickness thermal burns covering less than 40% of body surface area (BSA) to receive either MEBO or C. Fifty-seven patients were assigned to MEBO and 58 patients to C. The latter group received twice-daily dressing changes; MEBO patients received MEBO every 4 hours. MAIN OUTCOME MEASURES: Patients were hospitalized until 75% BSA had healed. BSA was determined by visual inspection and charted on Lund and Browder charts regularly. Wound healing rate, bacterial infection rate, pain score, and hospitalization costs were recorded. RESULTS: The median time to 75% healing was 17.0 and 20.0 days with MEBO and C, respectively (HR = 0.67, 95% CI = 0.41-1.11, P =.11), suggesting similar efficacy between the 2 modalities. Bacterial infection rates were similar between the 2 groups (HR = 1.10, 95% CI = 0.59-2.03, P =.76). MEBO imparted a greater analgesic effect in the first 5 days of therapy and reduced hospital costs by 8%. CONCLUSIONS: MEBO is as effective as conventional management but is not the panacea for all burn wounds. The use of MEBO eases the management of face and neck burns and facilitates early institution of occupational therapy in hand burns. It confers better pain relief such that fewer opiates are used during the first 5 days after burn injury.