The risk factors for complications and survival outcomes of Klebsiella pneumoniae Bacteraemia in Hospital Canselor Tuanku Muhriz Universiti Kebangsaan Malaysia.

INTRODUCTION: Mortality of Klebsiella pneumoniae (K. pneumoniae) bacteraemia was reported to be on the rise globally. The 30-day mortality rate of K. pneumoniae bacteraemia ranges from 16% to 55% in Beijing, Shanghai, and Taiwan. However, there is a lack of research on the survival outcomes of K. pneumoniae bacteraemia in Malaysia. The objectives of this study were to determine the poor prognostic factors and predictors of 14-day in-hospital mortality from K. pneumoniae bacteraemia. METHODS: This was a retrospective cohort study of patients with K. pneumoniae bacteraemia in Hospital Canselor Tuanku Muhriz Universiti Kebangsaan Malaysia (HCTM). We included adult patients with blood cultures positive for K. pneumoniae between 1 January 2016 and 31 December 2019. Those with polymicrobial bacteraemia were excluded. Medical records were reviewed to obtain the sociodemographic data, gender, underlying comorbidities, invasive procedures at presentation, sources of bacteraemia, and whether appropriate empirical and definitive antibiotics was given on time. Data regarding complications of K. pneumoniae bacteraemia, including liver abscess, endopthalmitis, septic shock, Quick Pitt (qPitt) bacteraemia score defined as hypothermia, hypotension, respiratory failure, cardiac arrest, and altered mental status and stay in intensive care unit (ICU) were also recorded. The main outcome measure used was the survival in 14 days. Summary of statistical analysis was done. RESULTS: A total of 260 patients with K. pneumoniae bacteraemia were included. All patients received appropriate empirical and definitive antibiotics within 24 h of the time that the sample for index blood cultures was obtained. Respiratory infection, septic shock, qPitt bacteraemia score ≥2, solid organ malignancy, stay in ICU, central venous line insertion at presentation, urinary catheterisation at presentation, and in-patient mechanical ventilation were identified as independent predictors of mortality in K. pneumoniae bacteraemia. The rate of complications such as liver abscess, endophthalmitis, ICU admission, and septic shock was not significantly different between survivors and non-survivors. The 14-day in-hospital mortality rate was 12.3%. The median length of hospitalisation was 11 days (IQR 6 - 19) . The predictors of poor prognosis for 14 days in-hospital mortality for K. pneumoniae bacteraemia were as follows: qPitt bacteraemia score ≥2, central venous line insertion, indwelling urinary catheter at presentation, and in-patient mechanical ventilation. Timing from K. pneumoniae bacteraemia event to death among those qPitt bacteraemia scores ≥2 was only for 9 days or less. CONCLUSIONS: The 14-day in-hospital mortality of patients with K. pneumoniae bacteraemia in our setting was low. The qPitt bacteraemia score ≥2 was the strongest predictor of poor prognosis for 14-day in-hospital mortality in patients with K. pneumoniae bacteraemia. The qPitt bacteraemia score should be proposed to be used as a bedside screening tool for gram negative bacteraemia in our daily clinical practice, which is also useful for predicting mortality in critically ill patients.

It starts from the womb: maximizing bone health.

The foundation of bone health is established in utero. Bone accrual starts from the developing fetus and continues throughout childhood and adolescence. This process is crucial to achieve peak bone mass. Understanding factors that influence bone accrual before attainment of peak bone mass is thus critical to improve bone health and prevent osteoporosis, thereby reducing the burden of osteoporotic fractures in older women. In this review, we broadly outline factors influencing peak bone mass from pregnancy to infancy, childhood and adolescence with potential diseases and medications that may affect the optimum trajectory to maximizing bone health. It is estimated that a 10% increase in peak bone mass will delay the onset of osteoporosis by 13 years in a woman.

Western Australian adolescent emotional wellbeing during the COVID-19 pandemic in 2020.

BACKGROUND: The impacts of the COVID-19 pandemic have been vast and are not limited to physical health. Many adolescents have experienced disruptions to daily life, including changes in their school routine and family's financial or emotional security, potentially impacting their emotional wellbeing. In low COVID-19 prevalence settings, the impact of isolation has been mitigated for most young people through continued face-to-face schooling, yet there may still be significant impacts on their wellbeing that could be attributed to the pandemic. METHODS: We report on data from 32,849 surveys from Year 7-12 students in 40 schools over two 2020 survey cycles (June/July: 19,240; October: 13,609), drawn from a study of 79 primary and secondary schools across Western Australia, Australia. The Child Health Utility Index (CHU9D) was used to measure difficulties and distress in responding secondary school students only. Using comparable Australian data collected six years prior to the pandemic, the CHU9D was calibrated against the Kessler-10 to establish a reliable threshold for CHU9D-rated distress. RESULTS: Compared to 14% of responding 12-18-year-olds in 2013/2014, in both 2020 survey cycles almost 40% of secondary students returned a CHU9D score above a threshold indicative of elevated difficulties and distress. Student distress increased significantly between June and October 2020. Female students, those in older Grades, those with few friendships or perceived poor quality friendships, and those with poor connectedness to school were more likely to score above the threshold. CONCLUSIONS: In a large dataset collected during the first year of the COVID-19 pandemic, the proportion of secondary school students with scores indicative of difficulties and distress was substantially higher than a 2013/2014 benchmark, and distress increased as the pandemic progressed, despite the low local prevalence of COVID-19. This may indicate a general decline in social and emotional wellbeing exacerbated by the events of the pandemic. TRIAL REGISTRATION: ANZCTRN (ACTRN12620000922976). Retrospectively registered 17/08/2020. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380429&isReview=true .

A pilot screening study for low bone mass in Singaporean women using years since menopause and BMI.

OBJECTIVE: Current risk assessment tools for osteoporosis have inconsistent performance across different cohorts, making them difficult for clinical practice. This study aimed to evaluate a simple screening index comprising years since menopause (YSM) and body mass index (BMI) that identifies postmenopausal Singaporean women with a greater likelihood of low bone mass. METHODS: The study used data from 188 treatment-naïve postmenopausal women. The associations between low bone mass and different demographic variables, including age, YSM and BMI, were assessed using multivariable logistic regression. Diagnostic performance of the calculated screening index was compared to the Osteoporosis Self-Assessment Tool for Asians (OSTA) and the Fracture Risk Assessment Tool (FRAX®). RESULTS: YSM and BMI were significantly associated with low bone mass. The area under the receiver operating characteristic curves was 0.803 for the screening index, 0.759 for the OSTA, 0.683 for the FRAX® (major osteoporotic fracture probability [MOFP]) and 0.647 for the FRAX® (hip fracture probability [HFP]). Non-parametric Spearman's correlation between the screening index and the other models was 0.857 with the OSTA score, 0.694 with the FRAX® (HFP) and 0.565 with the FRAX® (MOFP) (p < 0.0005). CONCLUSIONS: The diagnostic performance of the screening index comprising YSM and BMI was equivalent to the OSTA and the FRAX®. A risk chart was developed for clinicians to identify and recommend subjects for a further dual-energy X-ray absorptiometry scan. Validation of this model in larger and more diverse cohorts is required.

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.

A "Stone in the Pond" Approach to Contact Tracing: Responding to a Large-Scale, Nosocomial Tuberculosis Exposure in a Moderate TB-Burden Setting.

A "stone in the pond" strategy is a practical approach to investigating large-scale nosocomial tuberculosis (TB) exposures. Here, we describe such a risk-stratified approach to contact tracing after a TB exposure that occurred over 5 months in a pediatric inpatient ward in a country with a moderate TB burden. Infect Control Hosp Epidemiol 2017;38:1509-1511.

Challenges faced by older nurses in Singapore: a mixed methods study.

BACKGROUND: In Singapore, employees aged 62-65 can continue to be employed if they meet the re-employment eligibility criteria. This policy, coupled with an ageing workforce, calls for age-friendly initiatives, specific to work-related challenges faced by older nurses. AIM: To determine work-related challenges faced by older nurses. METHODS: A mixed method sequential explanatory study was conducted with nurses, aged 50 and above, working in a healthcare cluster in Singapore. In the quantitative phase, a questionnaire was administered to 534 nurses to elicit work-related challenges, then in-depth interviews with 30 nurses were carried out to help explain why certain tasks and work circumstances became harder. RESULTS: Results of the survey indicated that the top three challenges were coping with changes, working with computers and reading labels. Place of work, salary range, gender and race were significantly associated with different work-related challenges. Five themes emerged from the qualitative data: physical demands of work and workload, new technology, need for further education, working with younger nurses and in intercultural teams, and changing public expectations and professional image. DISCUSSION AND CONCLUSION: The study supports the current literature on the challenges older nurses face with technological advancement. However, older nurses in our study reported less aches and pain as compared to that reported elsewhere. There is a need for specific strategies that will address changes in work processes and environment in order to retain older nurses. IMPLICATIONS FOR NURSING AND NURSING POLICY: When devising age-friendly work improvement initiatives, it is important for nurse leaders to factor in the needs of nurses working in different care environments, who are of different ranks, or are from different ethnic backgrounds.

Assessment of the level of knowledge of colorectal cancer among public at outpatient clinics in Serdang Hospital: a survey based study.

OBJECTIVES: Colorectal cancer (CRC) is one of the most common gastrointestinal cancers in the world. In the Asia- Pacific region, it is the fastest emerging gastrointestinal cancer. Level of awareness on CRC warning signs and risk factors in the rural population of Malaysia is reported of very low. The aim of this study was to assess the level of knowledge of CRC among the public at medical outpatient clinics in Serdang Hospital. The association between sociodemographic factors with level of knowledge among the respondents was further studied. STUDY DESIGN: A study was conducted among the non-CRC patients' relatives accompanying their relatives to the medical outpatient clinics in Serdang Hospital from 1st April to 31st August 2016. The study was carried out with cluster sampling method. METHODS: The respondents were assessed using validated and modified Cancer Awareness Measures (CAM) questionnaire consists of three parts which are knowledge on warning signs, knowledge on risk factors and sociodemographic factors. All data were analysed using IBM SPSS Statistics 21.0. RESULTS: Altogether 308 subjects completed the questionnaires. It was shown high percentage of good knowledge for warning signs and risk factors of CRC among the respondents. A significant association between age groups and level of income with level of knowledge on warning signs was observed. CONCLUSIONS: The level of knowledge of CRC among the general public in Serdang Hospital was sufficient. The respondents with higher income or younger age had higher level of knowledge regarding CRC.

Increased risk of strontium ranelate-related SJS/TEN is associated with HLA.

UNLABELLED: Severe adverse drug reactions (ADR) of Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) in some patients receiving strontium ranelate have been reported, but the risk factors are unclear. We show that HLA-A*33:03 and B*58:01 are significantly associated with patients who developed SJS/TEN; and provide the first evidence that genetic risk factors are involved in strontium ranelate-associated SJS/TEN. INTRODUCTION: In this study, HLA as a genetic risk factor was assessed among osteoporotic patients prescribed with strontium ranelate that developed severe cutaneous adverse drug reactions (SCARs) compared with those who were tolerant. METHODS: Genomic DNA isolated from peripheral blood mononuclear cells (PBMCs) of patients was HLA typed using sequencing-based typing method to determine their HLA profiles. RESULTS: Osteoporotic patients who are currently on strontium ranelate were enrolled in the study (n = 76). Tolerant controls were defined as patients who received strontium ranelate for a minimum of 3 months (range 3 months to 8 years) with no reports of any cutaneous reactions as these reactions usually occur within the first 12 weeks after starting treatment. Retrospective cases of SJS/TEN were also identified (n = 5). The majority of the accrued samples were of Han Chinese descent: controls (n = 72) and cases (n = 4). All cases and controls were genotyped at four HLA genes, namely HLA-A, HLA-B, HLA-C, and HLA-DRB1. In comparing the samples of Han Chinese descent (72 controls and 4 cases), we found significant associations with HLA-A*33:03 (p = 0.002) and HLA-B*58:01 (p = 0.023). There was no significant association with any HLA-C or HLA-DRB1 alleles. CONCLUSIONS: This study reveals that the occurrence of SJS/TEN in Han Chinese patients receiving strontium ranelate is HLA associated. This has important clinical implications for understanding the underlying mechanisms for this ADR as well as evaluating the potential role of genetic pre-screening for osteoporotic patients who may be prescribed strontium ranelate.

Heterogeneous photo-Fenton reaction on hematite (α-Fe2O3){104}, {113} and {001} surface facets.

The exposed surface facets play an important role in determining the catalytic performance of nanostructured materials. In this study, we report the synthesis of hematite nanoparticles with three varying morphologies with exposure of well-controlled {104}, {113} and {001} surfaces. The better shape control of hematite particles has provided a direct correlation between the surface facets and the photocatalytic performance. The catalytic photodegradation of MB using hematite nanoparticles reveals that the reaction follows the heterogeneous photo-Fenton process under visible light irradiation. The catalytic performance of hematite surface facets follows the order of {113} > {104} > {001}. Density functional theory (DFT) calculations were conducted to demonstrate the atomic surface structures and the corresponding charge distribution. The results indicate that the catalytic activity depends on surface atom arrangements as well as the number and the type of surface terminated hydroxyl groups bonding to underlying Fe atoms, where low valence states of Fe on {104} and {113} planes have the highest probability to be oxidized by H2O2 and the concurrently generated Fe((3+x)+) sites are more electronegative to accept electrons from activated dye molecules. The findings are of fundamental importance to understand the surface-dependence of photocatalytic properties, thus shedding new light on the catalytic application of hematite particles.

Association of proinflammatory cytokines and chemotherapy-associated cognitive impairment in breast cancer patients: a multi-centered, prospective, cohort study.

BACKGROUND: Existing evidence suggests that proinflammatory cytokines play an intermediary role in postchemotherapy cognitive impairment. This is one of the largest multicentered, cohort studies conducted in Singapore to evaluate the prevalence and proinflammatory biomarkers associated with cognitive impairment in breast cancer patients. PATIENTS AND METHODS: Chemotherapy-receiving breast cancer patients (stages I-III) were recruited. Proinflammatory plasma cytokines concentrations [interleukin (IL)-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating factor, interferon-γ and tumor necrosis factor-α] were evaluated at 3 time points (before chemotherapy, 6 and 12 weeks after chemotherapy initiation). The FACT-Cog (version 3) was utilized to evaluate patients' self-perceived cognitive disturbances and a computerized neuropsychological assessment (Headminder) was administered to evaluate patients' memory, attention, response speed and processing speed. Changes of cognition throughout chemotherapy treatment were compared against the baseline. Linear mixed-effects models were applied to test the relationships of clinical variables and cytokine concentrations on self-perceived cognitive disturbances and each objective cognitive domain. RESULTS: Ninety-nine patients were included (age 50.5 ± 8.4 years; 81.8% Chinese; mean duration of education = 10.8 ± 3.3 years). Higher plasma IL-1ß was associated with poorer response speed performance (estimate: -0.78; 95% confidence interval (CI) -1.34 to -0.03; P = 0.023), and a higher concentration of IL-4 was associated with better response speed performance (P = 0.022). Higher concentrations of IL-1ß and IL-6 were associated with more severe self-perceived cognitive disturbances (P = 0.018 and 0.001, respectively). Patients with higher concentrations of IL-4 also reported less severe cognitive disturbances (P = 0.022). CONCLUSIONS: While elevated concentrations of IL-6 and IL-1ß were observed in patients with poorer response speed performance and perceived cognitive disturbances, IL-4 may be protective against chemotherapy-associated cognitive impairment. This study is important because cytokines would potentially be mechanistic mediators of chemotherapy-associated cognitive changes.

Infliximab reverses inflammatory muscle wasting (sarcopenia) in Crohn's disease.

BACKGROUND: Muscle wasting or sarcopenia arising from chronic inflammation is found in 60% of patients with Crohn's disease. Transcriptional protein NF-κB reduces muscle formation through MyoD transcription and increases muscle breakdown by proteolysis. AIM: As TNF is a potent activator of NF-κB, and anti-TNF agent infliximab (IFX) prevents NF-κB activation, to determine whether or not Crohn's patients treated with IFX gain muscle volume and strength. METHODS: We performed a prospective, repeated-measures cohort study in adult Crohn's disease patients with an acute disease flare. Patients were instructed not to vary diet or activity. Concomitant medications were kept stable. At week 1 (pre-treatment), week 16 (post-IFX induction) and week 25 (post-first IFX maintenance dose), we assessed (i) MRI volume of quadriceps femoris at anatomical mid-thigh; (ii) maximal concentric quadriceps contractions strength at three specific speeds of contraction; (iii) physical activity by validated instrument (IPAQ); (iv) Three-day food record of intake and composition (food-weighing method); (v) Serum levels of IL6. RESULTS: Nineteen patients (58% female; mean age 33.2 ± 10.7 years) were recruited. IFX increased muscle volume in both legs from baseline (right, 1505 cm(3) ) to week 25 (right, 1569 cm(3) ; P = 0.010). IFX also increased muscle strength in both legs from baseline (right 30°/s, 184.8 Nm) to week 25 (right 30°/s, 213.6 Nm; P = 0.002). Muscle volume gain correlated with male gender (P = 0.003). Significant gains in muscle volume and strength were unrelated to prednisolone use. Serum IL6 levels decreased by week 25 (P = 0.037). CONCLUSION: The anti-TNF agent infliximab reverses inflammatory sarcopenia in patients with Crohn's disease.

Preliminary assessment of the SensiumVitals®: A low-cost wireless solution for patient surveillance in the general wards.

This paper presents SensiumVitals(®) - an FDA cleared and CE marked wireless wearable vital signs monitoring system, developed for frequent surveillance of in-hospital patients. A number of in-house evaluations with artificial data and healthy volunteers were carried out in different stages to assess the reliability of two crucial vital signs measured by the system - respiration and heart rate. In order to illustrate the potential of the system in hospital, a subset of data collected from acutely-ill patients during a separate clinical trial was also analyzed. In all cases the results revealed satisfactory agreement between the values reported by SensiumVitals(®) and those recorded simultaneously by a clinically-approved bedside monitor. However, further work will be required to improve the reliability of the system under certain clinical conditions; which, although not crucial for our intended population (i.e. patients in general ward), pose interesting challenges for upgrading our technology for future use in these types of patients.

Use of emollients in atopic dermatitis.

Atopic dermatitis (AD) is a common inflammatory skin disorder that has strong financial and psychosocial impacts. Its pathogenesis is related to increased transepidermal water loss due to a defective skin epidermal barrier. Emollients serve as first-line therapy during both acute flares and remission. However, their use is poorly characterized, posing therapeutic challenges to clinicians and patients. In this article, we review available evidence to provide recommendations, aiming to standardize and optimize the use of emollients in AD. Literature search was performed using Pubmed and Google. All articles were retrieved using Pubmed. Recommendations were graded based on the British Medical Journal's Grading of Recommendations Assessment, Development and Evaluation system and the American Academy of Family Physicians' Strength of Recommendation Taxonomy. Emollients should be applied post-bathing. However, the need for immediate application is debatable. The optimal frequency for application is still undetermined, but multiple applications daily are encouraged. Ideally, a balance should be achieved between patient's compliance and clinical efficacy. Emollients hold the potential to act as steroid-sparing agents, but more well-designed studies are pertinent for a definite conclusion. At present, it is recommended that 250-500 g of emollients be applied every week. Finally, primary prevention of AD by regular application of emollients in high-risk infants cannot yet be recommended.

Isolation, screening, and identification of potential cellulolytic and xylanolytic producers for biodegradation of untreated oil palm trunk and its application in saccharification of lemongrass leaves.

This study presents the isolation and screening of fungi with excellent ability to degrade untreated oil palm trunk (OPT) in a solid-state fermentation system (SSF). Qualitative assay of cellulases and xylanase indicates notable secretion of both enzymes by 12 fungal strains from a laboratory collection and 5 strains isolated from a contaminated wooden board. High production of these enzymes was subsequently quantified in OPT in SSF. Aspergillus fumigates SK1 isolated from cow dung gives the highest xylanolytic activity (648.448 U g(-1)), generally high cellulolytic activities (CMCase: 48.006, FPase: 6.860, beta-glucosidase: 16.328 U g(-1)) and moderate lignin peroxidase activity (4.820 U/g), and highest xylanolytic activity. The xylanase encoding gene of Aspergillus fumigates SK1 was screened using polymerase chain reaction by a pair of degenerate primers. Through multiple alignment of the SK1 strain's xylanase nucleotide sequences with other published xylanases, it was confirmed that the gene belonged to the xylanase glycoside hydrolase family 11 (GH11) with a protein size of 24.49 kD. Saccharification of lemongrass leaves using crude cellulases and xylanase gives the maximum reducing sugars production of 6.84 g/L with glucose as the major end product and traces of phenylpropanic compounds (vanillic acid, p-coumaric acid, and ferulic acid).

Ministry of Health Clinical Practice Guidelines: Diabetes Mellitus.

The Ministry of Health (MOH) have updated the clinical practice guidelines on Diabetes Mellitus to provide doctors and patients in Singapore with evidence-based treatment for diabetes mellitus. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Diabetes Mellitus, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Experience with the use of the Codonics Safe Label System(™) to improve labelling compliance of anaesthesia drugs.

The Codonics Safe Labeling System(™) (http://www.codonics.com/Products/SLS/flash/) is a piece of equipment that is able to barcode scan medications, read aloud the medication and the concentration and print a label of the appropriate concentration in the appropriate colour code. We decided to test this system in our facility to identify risks, benefits and usability. Our project comprised a baseline survey (25 anaesthesia cases during which 212 syringes were prepared from 223 drugs), an observational study (47 cases with 330 syringes prepared) and a user acceptability survey. The baseline compliance with all labelling requirements was 58%. In the observational study the compliance using the Codonics system was 98.6% versus 63.8% with conventional labelling. In the user acceptability survey the majority agreed the Codonics machine was easy to use, more legible and adhered with better security than the conventional preprinted label. However, most were neutral when asked about the likelihood of flexibility and customisation and were dissatisfied with the increased workload. Our findings suggest that the Codonics labelling machine is user-friendly and it improved syringe labelling compliance in our study. However, staff need to be willing to follow proper labelling workflow rather than batch label during preparation. Future syringe labelling equipment developers need to concentrate on user interface issues to reduce human factor and workflow problems. Support logistics are also an important consideration prior to implementation of any new labelling system.