Three-year epidemiology of hospitalised paediatric burn patients in a Malaysian Tertiary Hospital 2016 - 2018.

INTRODUCTION: Burn injuries incur not just significant morbidity but also long-term psychosocial impact. This study aims to identify the clinico-demographics of children hospitalised for burns and factors associated with prolonged hospitalisation. MATERIALS AND METHODS: Written medical records of burn patients admitted to the Sultanah Aminah Hospital paediatric surgical ward, from January 2016 to December 2018, were retrospectively reviewed. Details on the patients' socio-demographic background, burn injuries, management and outcomes were recorded and analysed with logistic regression. RESULTS AND CONCLUSION: Of the 255 children included in the study, the majority were males (62.7%), children aged between 1 to 3 years (43.1%), and of the Malay ethnic group (83.1%). The commonest injury mechanism was scalds burns (81.2%). Staphylococcus aureus remained the commonest organism cultured from paediatric burn wounds. Most patients (66.4%) were hospitalised for less than 1 week. A significant number of patients experienced complications from their injuries. Multivariate analysis showed burns affecting total body surface area > 10% (adjusted OR, 13.45 [95% CI 6.25 - 28.96]; p = < 0.001) and non-scald burns (adjusted OR, 2.70 [95% CI 1.12 - 6.50]; p = 0.027) were the two main factors associated with prolonged hospitalisation of more than 1 week. These findings describing the epidemiology and outcomes of paediatric burn cases in a tertiary centre in Malaysia may inform future practice. More importantly, the information may contribute to the identification of at-risk populations and advise the development of effective prevention strategies to reduce the incidence and morbidity associated with paediatric burns in this region.

Staged Reconstruction for Humeral Osteomyelitis after Severe Crush Injury of the Shoulder: A Case Report.

The incidence of humeral osteomyelitis is relatively rare as compared to incidence of lower limb osteomyelitis. Despite having no guideline in the management of humeral osteomyelitis, surgeons have utilised their experience in managing lower limb osteomyelitis to treat humeral osteomyelitis. By adhering to principles including thorough debridement of necrotic bone and soft tissue, staged bony and/or soft tissue reconstruction, and targeted antimicrobial therapy, a good outcome can be achieved in the management of humeral osteomyelitis. We report a case of Cierny-Mader type IV proximal humeral osteomyelitis after a severe crush injury of the left shoulder and its subsequent two-stage reconstruction using internal fixation and pedicled Latissimus dorsi musculocutaneous flap.

Characteristics and Microbiological Profile of Patients with Diabetic Foot Infections in Kuantan, Pahang.

Introduction: The number of people suffering from diabetic foot infection (DFI) has increased precipitously over the years in Malaysia, owing to increased population, urbanisation, the surge of number of people with obesity and physical inactivity. As one of the most dreaded complications of diabetes mellitus, DFI is associated with high morbidity and mortality. We aim to study the microbiological profile of patients with DFI at a university hospital in Kuantan, Pahang. Materials and methods: This retrospective study was carried out at at Sultan Ahmad Shah Medical Centre @IIUM (SASMEC @IIUM) from 1 January 2018 to 30 April 2019. Patients' demographic data, types of infection and surgical intervention, and the microbiological profile were obtained from the medical records. Results: A total of 142 causative pathogens were cultured from 130 tissue samples, with an average of 1.09 pathogens per lesion. Majority of the pathogens were gram-negative pathogens (52.8%). Staphylococcus sp. was the most common pathogen isolated (22.5%). This was followed by Streptococcus sp. (10.6%), Pseudomonas sp. (9.2%), Morganella sp. (5.6%), Klebsiella sp. (4.9%), Enterobacter sp. (4.9%), and others. Among the 142 pathogens, there were 9 multidrug-resistant strains observed. Most of the antibiotics were effective against the gram-positive pathogens except benzylpenicillin, tetracyclin, fusidic acid and ciprofloxacin. Meanwhile, cefotaxime, amoxicillin and ampicillin-sulbactam were also not suitable against gramnegative pathogens. Oxacillin and sulfamethoxazole/ trimethoprim can be used as empirical antibiotics against gram-positive pathogens, while vancomycin should be reserved for patients with septic shock or suspected multidrug resistant strain infection. Piperacillin/tazobactam and ceftazidime can be used as empirical antibiotics against gram-negative pathogens. Conclusion: Early initiation of empirical antibiotic(s) is paramount to stymie the infection from getting worse while waiting for the identification of causative pathogens in the management of DFI. This study provides a guide for treating physicians to initiate the most appropriate empirical antibiotic in DFI.

Ranking negative emissions technologies under uncertainty.

Existing mitigation strategies to reduce greenhouse gas (GHG) emissions are inadequate to reach the target emission reductions set in the Paris Agreement. Hence, the deployment of negative emission technologies (NETs) is imperative. Given that there are multiple available NETs that need to be evaluated based on multiple criteria, there is a need for a systematic method for ranking and prioritizing them. Furthermore, the uncertainty in estimating the techno-economic performance levels of NETs is a major challenge. In this work, an integrated model of fuzzy analytical hierarchy process (AHP) and interval-extended Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) is proposed to address the multiple criteria, together with data uncertainties. The potential of NETs is assessed through the application of this hybrid decision model. Sensitivity analysis is also conducted to evaluate the robustness of the ranking generated. The result shows Bioenergy with Carbon Capture and Storage (BECCS) as the most optimal alternative for achieving negative emission goals since it performed robustly in the different criteria considered. Meanwhile, energy requirement emerged as the most preferred or critical criterion in the deployment of NETs based on the decision-maker. This paper renders a new research perspective for evaluating the viability of NETs and extends the domains of the fuzzy AHP and interval-extended TOPSIS hybrid model.

Inspiratory muscle training at sea level improves the strength of inspiratory muscles during load carriage in cold-hypoxia.

Inspiratory muscle training (IMT) and functional IMT (IMTF: exercise-specific IMT activities) has been unsuccessful in reducing respiratory muscle fatigue following load carriage. IMTF did not include load carriage specific exercises. Fifteen participants split into two groups (training and control) walked 6 km loaded (18.2 kg) at speeds representing ∼50%V̇O2max in cold-hypoxia. The walk was completed at baseline; post 4 weeks IMT and 4 weeks IMTF (five exercises engaging core muscles, three involved load). The training group completed IMT and IMTF at a higher maximal inspiratory pressure (Pimax) than controls. Improvements in Pimax were greater in the training group post-IMT (20.4%, p = .025) and post-IMTF (29.1%, p = .050) compared to controls. Respiratory muscle fatigue was unchanged (p = .643). No other physiological or subjective measures were improved by IMT or IMTF. Both IMT and IMTF increased the strength of respiratory muscles pre-and-post a 6 km loaded walk in cold-hypoxia. Practitioner Summary: To explore the interaction between inspiratory muscle training (IMT), load carriage and environment, this study investigated 4 weeks IMT and 4 weeks functional IMT on respiratory muscle strength and fatigue. Functional IMT improved inspiratory muscle strength pre-and-post a loaded walk in cold-hypoxia but had no more effect than IMT alone. Abbreviations: ANOVA: analysis of variance; BF: breathing frequency; CON: control group; EELV: end-expiratory lung volume; EXP: experimental group; FEV1: forced expiratory volume in one second; FiO2: fraction of inspired oxygen; FVC: forced vital capacity; HR: heart rate; IMT: inspiratory muscle training; IMTF: functional inspiratory muscle training; Pemax: maximal expiratory pressure; Pimax: maximal inspiratory pressure; RMF: respiratory muscle fatigue; RPE: rate of perceived exertion; RWU: respiratory muscle warm-up; SaO2: arterial oxygen saturation; SpO2: peripheral oxygen saturation; V̇E: minute ventilation; V̇O2: rate of oxygen uptake.

Induction approach via P-Graph to rank clean technologies.

Identification of appropriate clean technologies for industrial implementation requires systematic evaluation based on a set of criteria that normally reflect economic, technical, environmental and other aspects. Such multiple attribute decision-making (MADM) problems involve rating a finite set of alternatives with respect to multiple potentially conflicting criteria. Conventional MADM approaches often involve explicit trade-offs in between criteria based on the expert's or decision maker's priorities. In practice, many experts arrive at decisions based on their tacit knowledge. This paper presents a new induction approach, wherein the implicit preference rules that estimate the expert's thinking pathways can be induced. P-graph framework is applied to the induction approach as it adds the advantage of being able to determine both optimal and near-optimal solutions that best approximate the decision structure of an expert. The method elicits the knowledge of experts from their ranking of a small set of sample alternatives. Then, the information is processed to induce implicit rules which are subsequently used to rank new alternatives. Hence, the expert's preferences are approximated by the new rankings. The proposed induction approach is demonstrated in the case study on the ranking of Negative Emission Technologies (NETs) viability for industry implementation.

Microbiology of diabetic foot infections in three district hospital in Malaysia and comparison with South East Asian Countries.

INTRODUCTION: Diabetic foot infection, a complication that is associated with lower-limb amputation, incurs a huge economic burden to the hospital and health care system of Malaysia. The bacteriological profile of pathogens in diabetic foot infections in Malaysia has been sparsely studied. We investigated the microbiology of diabetic foot infections in patients admitted to the district hospitals on the east coast of Malaysia. METHODS: A retrospective analysis was conducted in three district hospitals (Hospital Kuala Lipis, Hospital Bentong and Hospital Raub) in Malaysia from 1st of January 2016 to 31st December 2016. The clinical specimens were cultured using Clinical and Laboratory Standards Institute (CLSI) guidelines. Antibiotic sensitivity testing to different antibiotics was carried out using the disc diffusion method. RESULT: A total of 188 pathogens were isolated from 173 patients, with an average of 1.09 pathogens per lesion. Majority of the pathogens isolated were gram negative pathogens (73.4%). The most commonly isolated pathogens were Staphylococcus aureus (17.5%). This was followed by Klebsiella spp. (17%), Pseudomonas spp. (15.4%) and Proteus spp. (13.8%). Gram positive pathogens were sensitive to most of the antibiotics tested except penicillin and fusidic acid. Gram negative pathogens were sensitive to all antibiotics tested except ampicillin and amoxicillin/clavulanic acid. Amikacin provide coverage for all gram negative pathogens in DFI. CONCLUSION: For the management of patient with infection in diabetic foot, the choice of antibiotic therapy depends on the sensitivity of the pathogens, the severity of the infection, the patient's allergies history, toxicity and excretion of the antibiotics.

Ultrastructural aspects of sylvatic dengue virus infection in Vero cell.

INTRODUCTION: Dengue virus (DENV), the causative agent of dengue disease exists in sylvatic and endemic ecotypes. The cell morphological changes and viral morphogenesis of two dengue ecotypes were examined at the ultrastructural level to identify potential similarities and differences in the surrogate model of enzootic host. MATERIALS AND METHODS: Vero cells were inoculated with virus at a multiplicity of infection (MOI) of 0.1. Cell cultures were harvested over a time course and processed for transmission electron microscopic imaging. RESULTS: The filopodia protrusions on cell periphery preceded virus entry. Additionally, sylvatic DENV infection was found spreading slower than the endemic DENV. Morphogenesis of both dengue ecotypes was alike but at different level of efficiency in the permissive cells. CONCLUSIONS: This is the first ultrastructural study on sylvatic DENV and this comparative study revealed the similarities and differences of cellular responses and morphogenesis of two dengue ecotypes in vitro. The study revealed the weaker infectivity of sylvatic DENV in the surrogate model of enzootic host, which supposed to support better replication of enzootic DENV than endemic DENV.

Predictive Factors of Major Lower Extremity Amputations in Diabetic Foot Infections: A Cross-sectional Study at District Hospital in Malaysia.

Introduction: Diabetic foot infection, a complication which can lead to lower limb amputation, is a major source of morbidity and mortality in Malaysia. The objective of this study was to determine the predictive factors of major lower limb amputation among patients with diabetes mellitus in a cluster of three district hospitals in Pahang, Malaysia. Materials and Methods: This cross-sectional study involved 170 patients who had undergone surgical interventions for diabetic foot infections at three district hospitals from 1st of September 2014 to 31st December 2015. The predictors for major amputation of lower limb were determined using simple logistic regression (LR) and forward LR multiple logistic regression. Results: A total of 21 patients had undergone major amputations of lower limb (15 transtibial and 6 transfemoral). The following factors were associated with major amputation of lower limb; longer duration of disease, age ≥ 60 years, patients from Bentong Hospital, presence of hypertension, presence of fever, history of multiple limb-salvaging surgeries, monomicrobial culture, necrotising fasciitis, anemia and leukocytosis. Upon forward LR multiple logistic regression, only duration of disease, history of more than three previous limb-salvaging surgeries and total white blood cell count ≥15X109/L were found to be significant as predictive factors of major amputation of lower limb. Conclusion: Among the factors analysed in this study, a longer duration of disease, raised total white blood cell count and history of more than three limb-salvaging surgeries were identified as predictors for major amputation of lower limb in diabetic foot infections using stepwise logistic regression analysis.

Late Presentation of Paediatric Pink Pulseless Supracondylar Fracture of Humerus: A Case Report.

Supracondylar humeral fracture is the most common elbow injury in children. It may be associated with a vascular injury in nearly 20% of the cases with a pink pulseless limb. We present a unique case of a paediatric pink pulseless supracondylar humeral fracture, seen late, on the 16th-day post-trauma. Open reduction, cross Kirschner wiring, and brachial artery exploration and repair were performed, and the patient recovered well. Early open reduction and exploration of the brachial artery with or without prior CT angiography was a safe approach in treating patients who presented at 16 days.

Incidence of vaginal erosion with different synthetic materials for suburethral sling in the treatment of Stress Urinary Incontinence: A systematic review.

INTRODUCTION: The aim of this systematic review is to compare the vaginal erosion rates in different synthetic materials used in suburethral slings in Tension Free Vaginal Tape (TVT-O /TOT) procedures in management of female stress urinary incontinence. METHODS: PRISMA 2009 framework was adopted for study design. Scholarly literature search was done using MEDLINE, EMBASE, the Cochrane Library and Clinical Trials.gov using selected keywords. Five articles fulfilled the inclusion and exclusion criteria. Our main outcome of interest is to review the ideal properties of the suburethral sling, procedure of insertion and post-surgical complication following the sling insertion primarily vaginal erosion. Results were compared using one way-ANOVA test and independent T- test. RESULTS: Total of 1725 subjects were available for analysis in the five studies. Monofilament polypropylene constituted 92.5% of the total sample size from one study alone. Polyester (n= 16/51) causes higher incidence rate of vaginal erosion compared to monofilament polypropylene (31.4 vs., 4.7; p = 0.01). There was no difference in the vaginal erosion rate between monofilament polypropylene and multifilament polypropylene (4.7 vs, 14.1; p=0.055) as well as between multifilament polypropylene and polyester (14.1 vs, 31.4; p=0.068). Although there was a marginally lower rate of vaginal erosion in TVT-O over TVT, the difference was not significant. (5.6 vs., 6.4, p=0.468). Common presentations of vaginal erosion were vaginal discharge, perineal pain and dyspareunia. CONCLUSION: Given the limited sample size, polyester sling material appears to cause higher rates of vaginal erosion. No difference in erosion rate was seen between TVT and TVT-O.

Do children undergoing bilateral myringotomy with placement of ventilating tubes benefit from pre-operative analgesia? A double-blinded, randomised, placebo-controlled trial.

OBJECTIVE: A double-blinded, randomised, placebo-controlled trial was conducted to determine whether routine pre-operative analgesia is beneficial in reducing post-operative ear pain following bilateral myringotomy and tube placement. METHODS: Forty-five children (aged 3-15 years) were randomised to receive either pre-operative analgesics (paracetamol and ibuprofen) (n = 21) or placebo (n = 24). All children underwent sevoflurane gas induction with intranasal fentanyl (2 mcg/kg) to reduce the incidence of emergence agitation. Post-operative pain scores were measured using the Wong-Baker Faces Pain Rating Scale. Median pain scores taken 90 minutes post-surgery, and the highest pain score recorded prior to 90 minutes, were analysed. RESULTS: There were no statistical differences between the median pain scores at 90 minutes or subsequent need for rescue analgesia. Emergence agitation did not occur in any child. Inadvertent ear trauma, use of an intravenous cannula or airway adjunct did not affect pain scores. CONCLUSION: Routine pre-operative analgesia does not reduce pain scores in the early post-operative period. Simple analgesics are effective for rescue analgesia in the minority of cases.