The effect of hypoxic ischemic encephalopathy towards multi-organ complications and its early outcome at a Malaysian district hospital.

INTRODUCTION: Hypoxic ischemic encephalopathy (HIE) is a clinically defined syndrome of disturbed neurologic function in the newborn with evidence of perinatal asphyxia. Stages of HIE are categorised into mild, moderate or severe based on the Sarnat classification. Neurological dysfunction constitutes a part of the wide spectrum of hypoxic ischemic insult as affected infants can have co-existing multi-organ dysfunction which further contributes to morbidities and mortality. This study aims to determine the relationship between the severity of HIE with multi-organ complications and early clinical outcomes. MATERIALS AND METHODS: All neonates who were admitted to the NICU at Hospital Sultan Abdul Halim between January 2018 to December 2022, who fulfilled the inclusion criteria were included. Demographic data, clinical course and investigation results were retrospectively obtained from the medical records. RESULTS: From a total of 90 infants (n = 90) who fulfilled our inclusion criteria, 31 (34%) were mild, 31 (34%) were moderate and 28 (31%) were severe HIE. The mean maternal age was 27 years. Common antenatal issues include diabetes mellitus (37.8%) and anaemia (22.2%). The Apgar scores at 1 and 5 minutes, initial resuscitation requiring intubation, chest compression and adrenaline were associated with higher severity of HIE (p < 0.05). Coagulation dysfunction was the most common complication (79.7%), followed by respiratory dysfunction (33.3%), cardiac dysfunction (28.9%), renal dysfunction (16.1%), haematological dysfunction (15.6%) and hepatic dysfunction (12%). Respiratory and haematological dysfunctions were significantly associated with higher mortality (p < 0.05). There was a significant longer hospital stay (p = 0.023), longer duration of ventilation (p < 0.001) and increase in frequency of seizures (p < 0.001) when comparing moderate and severe HIE patients to mild HIE patients. With increasing severity of HIE, there was also statistically significant higher mortality (p < 0.001). CONCLUSIONS: There is a significant relationship between multiorgan dysfunction, the severity of HIE and mortality. Early anticipation of multi-organ injury is crucial for optimal early management which would reduce the mortality and improve the neurological outcome of the patients.

A rare case of gouty arthropathy in the spine complicated with acute cord compression.

Gout is one of the most common inflammatory arthropathies in the developed world. However, involvement of the spine is relatively rare, and other sinister differential diagnoses will need to be considered. We describe an unusual case of gouty tophi deposition within the spine in an elderly patient presenting with signs and symptoms of acute cord compression. Important differential diagnoses that need to be excluded include bony metastases from underlying malignancy and other infective/inflammatory causes. Early recognition of imaging findings can avoid delayed or inappropriate medical treatment.

Clinical characteristics and outcomes of influenza-associated pulmonary aspergillosis among critically ill patients: a systematic review and meta-analysis.

BACKGROUND: Invasive pulmonary aspergillosis is increasingly identified as a complication of influenza, termed 'influenza-associated pulmonary aspergillosis' (IAPA). AIMS: To assess the morbidity and mortality of critically ill influenza patients with and without IAPA. METHODS: PubMed, Cochrane Library, Scopus and Embase databases were searched for studies containing comparative data of critically ill influenza patients with IAPA. Primary outcomes were all-cause in-hospital and intensive care unit (ICU) mortality. Secondary outcomes were clinical characteristics; duration of invasive mechanical ventilation (IMV); ICU and hospital length of stay (LOS); and requirement for vasopressor, renal replacement therapy (RRT) and extracorporeal membrane oxygenation (ECMO). FINDINGS: The incidence of IAPA was 28.8% in 853 critically ill influenza patients, with an overall mortality rate of 33.4%. No differences in age and comorbidities were observed. Patients with IAPA were predominantly male and received chronic corticosteroids. In-hospital (49.2% vs 27.0%; P=0.002) and ICU (46.8% vs 20.8%; P<0.001) mortality rates were higher among patients with IAPA than in patients without IAPA. A greater proportion of patients with IAPA required IMV, and had a prolonged IMV duration (mean 17.3 vs 10.5 days; P<0.001), ICU LOS (mean 26.8 vs 12.8 days; P=0.001) and hospital LOS (mean 38.7 vs 27.0 days; P=0.003). Patients with IAPA had greater disease severity and were significantly more likely to require vasopressor (76.4% vs 57.9%; P<0.001), RRT (45.7% vs 19.1%; P<0.001) and ECMO (25.9% vs 12.8%; P=0.004) support compared with patients without IAPA. CONCLUSIONS: A diagnosis of IAPA in critically ill patients is associated with greater morbidity and mortality. Early recognition and more research are needed to determine better diagnostic and treatment strategies.

Incidence, diagnosis and outcomes of COVID-19-associated pulmonary aspergillosis (CAPA): a systematic review.

COVID-19-associated pulmonary aspergillosis (CAPA) is defined as invasive pulmonary aspergillosis occurring in COVID-19 patients. The purpose of this review was to discuss the incidence, characteristics, diagnostic criteria, biomarkers, and outcomes of hospitalized patients diagnosed with CAPA. A literature search was performed through Pubmed and Web of Science databases for articles published up to 20th March 2021. In 1421 COVID-19 patients, the overall CAPA incidence was 13.5% (range 2.5-35.0%). The majority required invasive mechanical ventilation (IMV). The time to CAPA diagnosis from illness onset varied between 8.0 and 16.0 days. However, the time to CAPA diagnosis from intensive care unit (ICU) admission and IMV initiation ranged between 4.0-15.0 days and 3.0-8.0 days. The most common diagnostic criteria were the modified AspICU-Dutch/Belgian Mycosis Study Group and IAPA-Verweij et al. A total of 77.6% of patients had positive lower respiratory tract cultures, other fungal biomarkers of bronchoalveolar lavage and serum galactomannan were positive in 45.3% and 18.2% of patients. The CAPA mortality rate was high at 48.4%, despite the widespread use of antifungals. Lengthy hospital and ICU stays ranging between 16.0-37.5 days and 10.5-37.0 days were observed. CAPA patients had prolonged IMV duration of 13.0-20.0 days. The true incidence of CAPA likely remains unknown as the diagnosis is limited by the lack of standardized diagnostic criteria that rely solely on microbiological data with direct or indirect detection of Aspergillus in respiratory specimens, particularly in clinical conditions with a low pretest probability. A well-designed, multi-centre study to determine the optimal diagnostic approach for CAPA is required.

Renal tubular dysfunction during long-term adefovir or tenofovir therapy in chronic hepatitis B.

BACKGROUND: Adefovir and tenofovir are nucleotide analogues used as long-term therapy of chronic hepatitis B. Side effects are few, but prolonged and high-dose therapy has been associated with proximal renal tubular dysfunction (RTD). AIM: To assess the incidence of RTD during long-term nucleotide therapy of chronic hepatitis B. METHODS: A total of 51 patients being treated at the Clinical Center, National Institutes of Health were studied. Diagnosis of RTD required de novo appearance of at least three of five features: hypophosphataemia, hypouricaemia, serum creatinine elevation, proteinuria or glucosuria. RESULTS: Among 51 patients treated for 1-10 (mean 7.4) years with adefovir (n = 42), tenofovir (n = 4) or adefovir followed by tenofovir (n = 5), 7 (14%) developed RTD. Time to onset ranged from 22 to 94 (mean 49) months with an estimated 10-year cumulative rate of 15%. All seven had low urinary percent maximal tubular reabsorption of phosphate (<82%). Patients with RTD were older (58 vs. 44 years; P = 0.01) and had lower baseline glomerular filtration rates (82 vs. 97 cc/min; P = 0.08) compared to those without; but did not differ in other features. Six patients with RTD were switched to entecavir, all subsequently had improvements in serum phosphate (2.0-3.0 mg/dL), creatinine (1.6-1.1 mg/dL), uric acid (2.7-3.8 mg/dL) and proteinuria. CONCLUSIONS: Renal tubular dysfunction develops in 15% of patients treated with adefovir or tenofovir for 2-9 years and is partially reversible with change to other antivirals. Monitoring for serum phosphate, creatinine and urinalysis is prudent during long-term adefovir and tenofovir therapy.

Evaluation of family-centred practices in the early intervention programmes for infants and young children in Singapore with Measure of Processes of Care for Service Providers and Measure of Beliefs about Participation in Family-Centred Service.

BACKGROUND: The primary purpose of this study was to report on an evaluation of the perceptions and beliefs of service providers towards family-centred practices in 11 early intervention programmes for infants and young children in Singapore. METHODS: The Measure of Processes of Care for Service Providers (MPOC-SP) and Measure of Beliefs about Participation in Family-Centred Service (MBP-FCS) were administered to 213 service providers made up of teachers, therapists, psychologists and social workers providing centre-based therapy to children with special needs who were below the age of 6 years. RESULTS: Exploratory factor analyses were performed with both scales. Nineteen of the 27 MPOC-SP items were retained and supported the original four-factor structure model. The exploratory factor analyses on MBP-FCS provided a less satisfactory outcome. Fourteen of the 28 items were retained and these loaded onto four factors. The two factors relating to Beliefs about benefits of FCS and Beliefs about the absence of negative outcomes from FCS failed to emerge as separate factors. Further multiple regressions indicated that more direct work with families and positive self-efficacy in implementing FCS contributed significantly to explaining service providers' positive perception towards family-centred practice in service delivery. CONCLUSIONS: This is the first time MPOC-SP and MBP-FCS were administered to a population in an Asian context. While MBP-FCS would benefit from further development work on its construct, MPOC-SP offered important insights into service providers' perspectives about family-centred practices that would have useful implications for professional and service development.

Sliding fragility of unrestrained equipment in critical facilities

Through the years, seismic design of buildings has been well developed and is continually updated and improved. Yet, nonstructural components housed in buildings are rarely designed with the same degree of consideration as buildings. As a result, buildings that remain structurally sound after a strong earthquake often lose their operational capabilities due to damage to their nonstructural components, such as piping systems, communication equipment and other types of components. The recent 1994 Nothridge, 1995 Kobe and 1999 Turkey and Taiwan earthquakes further demonstrate the importance of controlling damage to nonstructural components, particularly in critical facilities, such as hospitals, in order to ensure their funcionality during and after a major earthquake. Earthquake vulnerability of nonstructural components is usually reduced by fastening or bracing individual objects. However, there are some nonstructural components in buildings which often cannot be restrained for protection from earthquake shaking. The response of these objects will consist of sliding, rocking or jumping. Understanding these response types will allow estimation of vulnerability to earthquake damage and will assist in the design of appropiate mitigation measures. This research concentrates on experimental and analytical studies of the sliding response of freestanding rigid objects subjected to base excitation. Analytical and experimental techniques are combined to allow determination of fragility curves for free-standing rigid equipment under seismic excitations for further improvement of seismic mitigation measures. A discrete system model, an analytical model for two-dimensional sliding under two-dimensional excitation, is developed and analyzed for specific base motions. Shaking table testing with a range of excitations and systems parameters is used to define stability bounds for pure sliding motion. A comparison of the analytical and experimental results is then performed to further verify the validity of the analytical model. Discrepancies in the model assumptions and future improvements of the nonstructural model are also discussed in this report (AU)

Outbreak of surgical wound infections associated with total hip arthroplasty.

OBJECTIVES: Describe an outbreak of surgical wound infections associated with total hip arthroplasty; identify risk factors for surgical wound infection during the pre-outbreak and outbreak periods. SETTING: A 100-bed hospital. From May 1 to September 30, 1988, 7 of 15 patients who underwent total hip arthroplasty developed surgical wound infections from Staphylococcus aureus (5), Enterobacter cloacae (1), beta-hemolytic streptococci (1), enterococci (1), coagulase-negative staphylococci (1), and Escherichia coli (1) (attack rate = 46.7%). DESIGN: Retrospective cohort studies comparing surgical wound infection rates by patient- and procedure-related risk factors during the pre-outbreak and outbreak periods were conducted. Drop plate quantitative air culturing was conducted in 10 consecutive total hip arthroplasties in the subsequent 6 months. RESULTS: Rates of surgical wound infection were surgically higher for arthroplasties in which no intraoperative prophylactic antimicrobials were given (44% versus 8%, relative risk [RR] = 5.4, p = .01), or in which the posterior approach (20% versus 3%, RR = 6.7, p = .04) or a specific prosthesis (39% versus 5%, RR = 6.3, p = 0.01) was used. The surgical wound infection rate was highest when one circulating nurse, Nurse A, assisted (47% versus 4%, RR = 12.8, p less than .001). Logistic regression analysis identified use of the posterior approach (RR = 1.8, p = .04) and Nurse A's participation (RR = 5.0, p less than .001) as independent risk factors for surgical wound infection. Interviews of the nursing supervisor indicated that Nurse A had recurrent dermatitis on her hands. During 6 months following Nurse A's reassignment, the rate declined significantly (from 7/15 to 0/10, p = .01). Drop plate culturing yielded 2 to 10 colonies per plate of organisms that did not match outbreak organisms. CONCLUSIONS: Outbreaks associated with personnel generally involve only 1 species. In this outbreak, Nurse A (possibly because of her dermatitis), technique, the posterior approach, and/or other undetermined factors were the primary predictors of surgical wound infection.

Fine needle aspiration cytology of a head and neck swelling in a child: a non-invasive approach to diagnosis.

A 12-year-old boy presented with a three-month history of a painful parotid swelling. Fine needle aspiration cytology indicated a pleomorphic adenoma--an uncommon lesion in a child. This diagnostic technique plays a useful role in the investigation of head and neck swellings.

Race and birth weight: the Chinese example.

In several studies a race-specific variation in birth weight was suggested between black infants and white infants. The following were compared: (1) the birth weight of Chinese infants born in mainland China, Taiwan, and the United States; and (2) the birth weight of Chinese infants and white infants born in the United States controlled for sociodemographic background. Similar birth weight distributions and incidence of low birth weight were found among Chinese infants born in the three areas with markedly different economic conditions. The women in all three areas appear to have met the basic health and nutritional needs for adequate fetal growth. Similar incidence of low birth weight with different birth weight distribution was found among infants born in the United States to two Chinese parents, to one Chinese parent and one white parent, and to two white parents. The variation in birth weight is greater for white infants than for Chinese infants and, consequently, more white infants had larger birth weight. The possibility of race-specific influences on birth weight distribution is suggested by these findings.

Mediastinitis and bilateral thoracic empyemas complicating adult epiglottitis.

A 32 year old woman developed life threatening mediastinitis and bilateral empyemas as a complication of adult epiglottitis. She recovered completely.