Application of root cause analysis and TEAMSTEPPS post intravesical gas explosion during transurethral resection of the prostate: a rare case report.

BACKGROUND: An intravesical gas explosion is a rare complication of transurethral resection of the prostate (TURP). It was first reported in English literature in 1926, and up to 2022 were only forty-one cases. Injury from an intravesical gas explosion, in the most severe cases appearing as extraperitoneal or intraperitoneal bladder rupture needed emergent repair surgery. CASE PRESENTATION: We present a case of a 75-year-old man who suffered an intravesical gas explosion during TURP. The patient underwent an emergent exploratory laparotomy for bladder repair and was transferred to the intensive care unit for further observation and treatment. Under the medical team's care for up to sixty days, the patient recovered smoothly without clinical sequelae. CONCLUSIONS: This case report presents an example of a rare complication of intravesical gas explosion during TURP, utilizing root cause analysis (RCA) to comprehend causal relationships and team strategies and tools to improve performance and patient safety (TeamSTEPPS) method delivers four teamwork skills that can be utilized during surgery and five recommendations to avoid gas explosions during TURP to prevent the recurrence of medical errors. In modern healthcare systems, promoting patient safety is crucial. Once complications appear, RCA and TeamSTEPPS are helpful means to support the healthcare team reflect and improve as a team.

Reanalysis of RNA sequencing data ends diagnostic odyssey and expands the phenotypic spectrum of congenital titinopathy.

Although next-generation sequencing has enabled diagnoses for many patients with Mendelian disorders, the majority remain undiagnosed. Here, we present a sibling pair who were clinically diagnosed with Escobar syndrome, however targeted gene testing was negative. Exome sequencing (ES), and later genome sequencing (GS), revealed compound heterozygous TTN variants in both siblings, a maternally inherited frameshift variant [(NM_133378.4):c.36812del; p.(Asp12271Valfs*10)], and a paternally inherited missense variant [(NM_133378.4):c.12322G > A; p.(Asp4108Asn)]. This result was considered nondiagnostic due to poor clinical fit and limited pathogenicity evidence for the missense variant of uncertain significance (VUS). Following initial nondiagnostic RNA sequencing (RNAseq) on muscle and further pursuit of other variants detected on the ES/GS, a reanalysis of noncanonical splice sites in the muscle transcriptome identified an out-of-frame exon retraction in TTN, near the known VUS. Interim literature included reports of patients with similar TTN variants who had phenotypic concordance with the siblings, and a diagnosis of a congenital titinopathy was given 4 years after the TTN variants had been initially reported. This report highlights the value of reanalysis of RNAseq with a different approach, expands the phenotypic spectrum of congenital titinopathy and also illustrates how a perceived phenotypic mismatch, and failure to consider known variants, can result in a prolongation of the diagnostic journey.

Cardiac and Neurological Complications Post COVID-19 Vaccination: A Systematic Review of Case Reports and Case Series.

Following mass vaccinations for the control of the COVID-19 epidemic, a spectrum of cardiac and neurological disorders was reported among vaccinated individuals. This study examined the range of complications documented and factors related to their occurrence. Three electronic databases were searched for case reports and case series with descriptions of cardiac and/or neurological complications in COVID-19 vaccine recipients. A total of 698 vaccinees were included in this review, of which 259 (37.1%) had cardiac and 439 (62.9%) had neurological complications. Inflammatory conditions were the commonest among the cardiac complications; while polyneuropathy, demyelinating diseases and cerebrovascular disorders were the more common neurological complications. The mean age of those with cardiac complications (33.8 years) was much younger than those with neurological complications (49.7 years). There was no notable difference in the gender distribution between these two groups of vaccine recipients. mRNA vaccines (all brands) were associated with almost 90.0% of the cardiac complications, whereas viral vector vaccines were associated with slightly over half (52.6%) of the neurological complications. With regard to the dose, cardiac complications were more common after the second (69.1%), whereas neurological complications were more common after the first dose (63.6%). The majority of the cases had an uncomplicated clinical course. Nevertheless, 5.9% of cases with neurological complications and 2.5% of those with cardiac complications were fatal, underscoring the significance of the consistent surveillance and vigilant monitoring of vaccinated individuals to mitigate these occurrences.

AMPK Drives both Glycolytic and Oxidative Metabolism in Murine and Human T Cells During Graft-versus-host Disease.

Allogeneic T cells reprogram their metabolism during acute graft-versus-host disease (GVHD) in a process involving the cellular energy sensor AMP-activated protein kinase (AMPK). Deletion of AMPK in donor T cells limits GVHD but still preserves homeostatic reconstitution and graft-versus-leukemia (GVL) effects. In the current studies, murine AMPK KO T cells decreased oxidative metabolism at early timepoints post-transplant and lacked a compensatory increase in glycolysis following inhibition of the electron transport chain. Immunoprecipitation using an antibody specific to phosphorylated targets of AMPK determined that AMPK modified interactions of several glycolytic enzymes including aldolase, enolase, pyruvate kinase M (PKM), and glyceraldehyde 3-phosphate dehydrogenase (GAPDH), and enzyme assays indicated impaired aldolase and GAPDH activity in AMPK KO T cells. Importantly, these changes in glycolysis correlated with both an impaired ability of AMPK KO T cells to produce significant amounts of interferon gamma (IFNγ) upon antigenic re-stimulation and a decrease in the total number of donor CD4 T cells recovered at later time points post-transplant. Human T cells lacking AMPK gave similar results, with glycolytic compensation impaired both in vitro and following expansion in vivo. GVHD results also mirrored those of the murine model, with reduced CD4/CD8 ratios and a significant improvement in disease severity. Together these data highlight a significant role for AMPK in controlling oxidative and glycolytic metabolism in both murine and human T cells and endorse further study of AMPK inhibition as a potential clinical target for future GVHD therapies.

Mechanistic modeling of twin screw wet granulation for pharmaceutical formulations: Calibration, sensitivity analysis, and model-driven workflow.

Wet granulation, a particle size enlargement process, can significantly enhance the critical quality attributes of powders and improve the ability to form tablets in pharmaceutical manufacturing. In this study, a mechanistic-based population balance model is applied to twin screw wet granulation. This model incorporated a recently developed breakage kernel specifically designed for twin screw granulation, along with nucleation, layering, and consolidation. Calibration and validation were performed on Hydrochlorothiazide and Acetaminophen formulations, which exhibit different particle size and wettability characteristics. Utilizing a compartmental experimental dataset, a comprehensive global sensitivity analysis identified critical inputs impacting quality attributes. The study revealed that the nucleation rate process model, effectively represented particle size distributions for both formulations. Adjustments to nucleation and breakage rate parameters, influenced by material properties and screw configuration, improved the model's accuracy. A model-driven workflow was proposed, offering step-by-step guidelines and facilitating PBM model usage, providing essential details for future active pharmaceutical ingredient (API) formulations.

Empowering people living with HIV (PLHIV): unveiling care gaps and identifying opportunities for improving care for PLHIV in Singapore and Hong Kong.

INTRODUCTION: This study explored the behaviours of people living with HIV in Singapore and Hong Kong in terms of achieving and maintaining their physical and psychological wellbeing in relation to HIV, to identify the challenges and support needed in HIV care. METHODS: This qualitative study involved 90-minute interviews among Singapore and Hong Kong people living with HIV aged ≥18 years to explore health-related quality of life perceptions and gaps in patient empowerment in HIV care during February-May 2022. The COM-B (C: Capability; O: Opportunity; M: Motivation; B: Behaviour) framework was used during data analysis to identify behaviour facilitators and barriers for people living with HIV to achieve and maintain their wellbeing. Detailed accounts of respondents' experience of living with and managing HIV, that is what worked well, unmet needs and perceived significance of wellbeing indicators, were analysed qualitatively via a combination of inductive content and deductive frameworks. RESULTS: A total of 30 and 28 respondents were recruited from Singapore (SG) and Hong Kong (HK), respectively. Most respondents were aged 20-49 years (SG: 83.3%; HK: 64.3%), males (SG: 96.7%; HK: 92.9%), men who have sex with men (SG: 93.3%; HK: 71.4%), had university or higher education (SG: 73.3%; HK: 50.0%) and were fully employed (SG: 73.3%; HK: 57.1%). In both Singapore and Hong Kong, physical health was considered a key focus of overall wellbeing, albeit attention to long-term health associated with cardiovascular and renal health was less salient. The impact of symptoms, side effects of treatment, mood and sleep were among the top wellbeing indicators of importance. Respondents felt that insufficient information was provided by physicians, citing consultation time and resource constraints impeding further expression of concerns to their physicians during consultation. Respondents prioritized functional wellness and delegated psychosocial health to supportive care professionals, patient groups, families and/or friends. CONCLUSIONS: There is a need in Singapore and Hong Kong to empower people living with HIV to establish better communications with their physicians and be more involved in their treatment journey and equally prioritize their psychosocial wellbeing.

The effectiveness of electronic screening and brief intervention for alcohol-related maxillofacial trauma: a randomized controlled trial.

OBJECTIVES: This study aims to deliver a novel web-app-based electronic Screening and Brief Intervention to patients with alcohol-related facial trauma and assess changes in at-risk drinking behaviors and attitudes toward their drinking and alcohol-related trauma. STUDY DESIGN, SETTING, AND SAMPLE: This was a 2-arm parallel randomized controlled trial. Participants who had sustained alcohol-related facial injuries were recruited from 3 Australian hospitals. RESULTS: Fifty-six participants were enrolled and randomized initially with 45 participants completing the questionnaire at baseline and 3-month follow-up. Most of the participants were male (71.1%), aged between 18 and 29 (40%), and presented to the ED for the first time (68.9%). The study revealed that the intervention group participants found the information provided via the e-SBI helpful in changing their drinking habits and seek help. The e-SBI intervention had a moderate effect on ASSIST Scores (d = -.59; 95% CI, -.03, 1.18). The effect sizes of the e-SBI on the secondary outcomes also ranged between small and moderate. CONCLUSIONS: The novel app-based e-SBI can effectively deliver information on harmful drinking and provide brief intervention and other venues for help and subsequently improve awareness and willingness to seek help and reduce the risk of injury recurrence.

Circular RNA as a source of neoantigens for cancer vaccines.

BACKGROUND: The effectiveness of somatic neoantigen-based immunotherapy is often hindered by the limited number of mutations in tumors with low to moderate mutation burden. Focusing on microsatellite-stable colorectal cancer (CRC), this study investigates the potential of tumor-associated circular RNAs (circRNAs) as an alternative source of neoepitopes in CRC. METHODS: Tumor-associated circRNAs in CRC were identified using the MiOncoCirc database and ribo-depletion RNA sequencing of paired clinical normal and tumor samples. Candidate circRNA expression was validated by quantitative real-time PCR (RT-qPCR) using divergent primers. TransCirc database was used for translation prediction. Human leukocyte antigen binding affinity of open reading frames from potentially translatable circRNA was predicted using pVACtools. Strong binders from messenger RNA-encoded proteins were excluded using BlastP. The immunogenicity of the candidate antigens was functionally validated through stimulation of naïve CD8+ T cells against the predicted neoepitopes and subsequent analysis of the T cells through enzyme-linked immunospot (ELISpot) assay, intracellular cytokine staining (ICS) and granzyme B (GZMB) reporter. The cytotoxicity of T cells trained with antigen peptides was further tested using patient-derived organoids. RESULTS: We identified a neoepitope from circRAPGEF5 that is upregulated in CRC tumor samples from MiOncoCirc database, and two neoepitopes from circMYH9, which is upregulated across various tumor samples from our matched clinical samples. The translation potential of candidate peptides was supported by Clinical Proteomic Tumor Analysis Consortium database using PepQuery. The candidate peptides elicited antigen-specific T cells response and expansion, evidenced by various assays including ELISpot, ICS and GZMB reporter. Furthermore, T cells trained with circMYH9 peptides were able to specifically target and eliminate tumor-derived organoids but not match normal organoids. This observation underscores the potential of circRNAs as a source of immunogenic neoantigens. Lastly, circMYH9 was enriched in the liquid biopsies of patients with CRC, thus enabling a detection-to-vaccination treatment strategy for patients with CRC. CONCLUSIONS: Our findings underscore the feasibility of tumor-associated circRNAs as an alternative source of neoantigens for cancer vaccines targeting tumors with moderate mutation levels.

Geophysical survey based on hybrid gravimetry using relative measurements and an atomic gravimeter as an absolute reference.

Gravimetry is a versatile metrological approach in geophysics to accurately map subterranean mass and density anomalies. There is a broad diversification regarding the working principle of gravimeters, wherein atomic gravimeters are one of the most technologically progressive class of gravimeters which can monitor gravity at an absolute scale with a high-repetition without exhibiting drift. Despite the apparent utility for geophysical surveys, atomic gravimeters are (currently) laboratory-bound devices due to the vexatious task of transportation. Here, we demonstrated the utility of an atomic gravimeter on-site during a gravity survey, where the issue of immobility was circumvented with a relative spring gravimeter. The atomic gravimeter served as a means to map the relative data from the spring gravimeter to an absolute measurement with an effective precision of 7.7 µ Gal. Absolute measurements provide a robust and feasible method to define and control gravity data taken at different sites, or a later date, which is critical to analyze underground geological units, in particular when it is combined with other geophysical approaches.

COVID-19 Vaccine Booster Hesitancy among the Elderly in Malaysian Residential Care Homes: A Cross-Sectional Study in Klang Valley.

The elderly are considered a high-risk group for severe outcomes and death from COVID-19 infection. Given the emergence of new COVID variants and the immunity provided by vaccines waning over time, booster doses of the vaccine have been advocated for those at risk to stay protected. This study aimed to determine the factors associated with hesitancy toward the second booster of the COVID-19 vaccine among the elderly residing in residential care homes. A cross-sectional study was conducted in 24 residential care homes in the Klang Valley using a face-to-face interview questionnaire. The study population included individuals aged 60 and above who had been fully vaccinated against COVID-19 up to the first booster dose. Second-booster hesitancy was assessed using the Oxford Vaccine Hesitancy Scale with seven items, the aggregate score of which ranges from seven to thirty-five; the higher the score, the greater the level of hesitancy. Multivariate linear regression was employed to determine factors associated with second-booster hesitancy, and a p-value < 0.05 was considered statistically significant. Data from 401 elderly individuals were included for analysis. The mean score of the Oxford Vaccine Hesitancy Scale was 21.6 ± 7.2. Predictors of second booster hesitancy were identified. Age, Indian ethnicity, being a recipient of the Sinovac vaccine as the first COVID-19 booster, experiencing the death of close friends or immediate family members following COVID-19 vaccination, and negative messages (indicating that taking a booster dose is harmful) from caregivers, friends, or family members were found to be associated with an increased second-booster-hesitancy score. Conversely, positive messages (indicating that taking a booster is helpful) from the government and caregivers, friends, or family members were identified as predictors associated with a reduction in the second-booster-hesitancy score. While vaccines effectively combat severe COVID-19, the majority of the elderly hesitate before taking the second booster. Their hesitancy, rooted in the perception of a low self risk and reliance on protection from the initial doses, emphasizes the need for intervention by relevant bodies. Taking into consideration the risk, albeit relatively low, of potentially serious side effects following COVID-19 vaccinations, it is imperative that transparent, appropriate, and positive messaging regarding booster vaccines, particularly in the context of the elderly from residential care homes, be available. Encouraging this high-risk group to embrace the second booster aligns with the goal of maximizing protection within the vulnerable elderly population.

Maternal and neonatal group B streptococcus colonisation: A systematic review and the meta-analysis of matched-pair studies.

AIM: To determine the prevalence of group B Streptococcus (GBS) carriage among parturient women and neonates, and the relative risk of vertical transmission, the relative risk of early and late-onset GBS and the pooled incidence of early-late-onset GBS infection. METHODS: A systematic search of relevant cohort studies from three electronic databases to identify all relevant studies published up to 7 November 2022. The review was conducted in accordance with PRISMA guidelines. Estimates were pooled using random-effects meta-analyses. RESULTS: A total of 54 articles with 355 787 matched pairs of parturient women and neonates from 30 countries were included in the analysis. The pooled prevalence of GBS colonisation was 17.1% among the pregnant women and 1.0% among neonates. The pooled prevalence of vertical transmission of GBS was 4.5% and the pooled relative risk of GBS colonisation of neonates born to mothers with GBS was 9.9. CONCLUSION: We support the implementation of targeted intrapartum antibiotic prophylaxis for all women who are positive for GBS as well as women with risks factors for early onset GBS in their infants regardless of their GBS colonisation status.

Ankle-brachial index associates with arteriovenous fistula stenosis.

BACKGROUND: Arteriovenous fistula (AVF) stenosis is associated with pre-existing arterial atherosclerosis of AVF and results in significant morbidity and hospitalization for hemodialysis patients. The ankle brachial index (ABI) is a noninvasive method of assessing atherosclerosis. This study was to examine whether ABI is a significant predictor for AVF stenosis. METHODS: This was a retrospective, longitudinal cohort study. Patients with hemodialysis between 1 January 2016 and 31 December 2022 were reviewed. ABI was assessed in January 2016. AVF stenosis was diagnosed by fistulography. RESULTS: A total of 82 patients were included. Forty-two patients experienced AVF stenosis. The univariate logistic regression analysis showed that AVF stenosis was associated with age (OR: 1.045, p = 0.033), DM status (OR: 5.529, p = 0.013), 7-year averaged cholesterol level (OR: 1.018, p = 0.034), 7-year averaged triglyceride level (OR: 1.007, p = 0.017), and ABI (OR: 0.011, p < 0.001). In multivariate logistic regression analysis, ABI was a strong predictor for AVF stenosis (OR: 0.036, p = 0.023). Then, a cut-off point of ABI with optimal sensitivity and specificity for AVF stenosis was 1.01. An analysis of time to events with adjustment for other variables showed that patients with ABI < 1.01 were significantly associated with AVF stenosis (HR: 3.859, p < 0.001). CONCLUSIONS: ABI below 1.01 was associated with AVF stenosis. This finding may be useful in tailoring surveillance programs for monitoring AVF function.

A functional personalised oncology approach against metastatic colorectal cancer in matched patient derived organoids.

Globally, colorectal cancer (CRC) is the third most frequently occurring cancer. Progression on to an advanced metastatic malignancy (metCRC) is often indicative of poor prognosis, as the 5-year survival rates of patients decline rapidly. Despite the availability of many systemic therapies for the management of metCRC, the long-term efficacies of these regimens are often hindered by the emergence of treatment resistance due to intratumoral and intertumoral heterogeneity. Furthermore, not all systemic therapies have associated biomarkers that can accurately predict patient responses. Hence, a functional personalised oncology (FPO) approach can enable the identification of patient-specific combinatorial vulnerabilities and synergistic combinations as effective treatment strategies. To this end, we established a panel of CRC patient-derived organoids (PDOs) as clinically relevant biological systems, of which three pairs of matched metCRC PDOs were derived from the primary sites (ptCRC) and metastatic lesions (mCRC). Histological and genomic characterisation of these PDOs demonstrated the preservation of histopathological and genetic features found in the parental tumours. Subsequent application of the phenotypic-analytical drug combination interrogation platform, Quadratic Phenotypic Optimisation Platform, in these pairs of PDOs identified patient-specific drug sensitivity profiles to epigenetic-based combination therapies. Most notably, matched PDOs from one patient exhibited differential sensitivity patterns to the rationally designed drug combinations despite being genetically similar. These findings collectively highlight the limitations of current genomic-driven precision medicine in guiding treatment strategies for metCRC patients. Instead, it suggests that epigenomic profiling and application of FPO could complement the identification of novel combinatorial vulnerabilities to target synchronous ptCRC and mCRC.

Challenges in Treating Extensive Deep Vein Thrombosis with Severe Thrombocytopenia in Patients with Antiphospholipid Syndrome-A Follow-up of 2 Years.

Thrombocytopenia is one of the most common manifestations of antiphospholipid syndrome (APS). There is little evidence or definitive guidelines regarding the treatment of APS with thrombocytopenia. We describe a patient with APS and moderate-to-severe thrombocytopenia and the challenges of balancing anticoagulation with thrombocytopenia. A 19-year-old male patient presented with right lower limb swelling to the emergency department with a history of gradually worsening right leg swelling for 1 week and was diagnosed with right leg proximal deep vein thrombosis. Ultrasound Doppler of the right lower limb revealed complete venous thrombosis from the level of the popliteal vein to the distal superficial femoral vein. Subsequently, he was found to have triple-positive APS and moderate-to-severe immune thrombocytopenia, with a platelet count nadir of 31 × 10 to the ninth power/L. He was started on anticoagulation with warfarin. The severe thrombocytopenia was not treated with immunosuppressants and the platelets fluctuated in the range of moderate-to-severe thrombocytopenia but did not develop any rethrombotic or bleeding events. His platelets varied from 31 × 10 to the ninth power/L to 106 × 10 to the ninth power/L. This case report demonstrates that it may be safe to hold off treatment for thrombocytopenia in APS, even in cases of severe thrombocytopenia. Treatment with immunosuppressants may be instituted only when platelet levels fall below 20 × 10 to the ninth power/L or when there is clinically significant bleeding, as in primary immune thrombocytopenia.

Did Descriptive and Prescriptive Norms About Gender Equality at Home Change During the COVID-19 Pandemic? A Cross-National Investigation.

Using data from 15 countries, this article investigates whether descriptive and prescriptive gender norms concerning housework and child care (domestic work) changed after the onset of the COVID-19 pandemic. Results of a total of 8,343 participants (M = 19.95, SD = 1.68) from two comparable student samples suggest that descriptive norms about unpaid domestic work have been affected by the pandemic, with individuals seeing mothers' relative to fathers' share of housework and child care as even larger. Moderation analyses revealed that the effect of the pandemic on descriptive norms about child care decreased with countries' increasing levels of gender equality; countries with stronger gender inequality showed a larger difference between pre- and post-pandemic. This study documents a shift in descriptive norms and discusses implications for gender equality-emphasizing the importance of addressing the additional challenges that mothers face during health-related crises.

Prevalence and factors associated with burnout among healthcare providers in Malaysia: a web-based cross-sectional study.

BACKGROUND: This study aimed to assess the determinants of burnout among healthcare providers in the primary care setting. METHODS: A web-based cross-sectional study was conducted among 1280 healthcare providers aged 18 years and older from 30 primary care clinics in Selangor, Malaysia. In this study, the Copenhagen Burnout Inventory was used to assess burnout. The results were analyzed using multiple logistic regression. RESULTS: The prevalence of personal burnout was 41.7%, followed by work-related burnout (32.2%) and client-related burnout (14.5%). The determinants for personal burnout in this study were younger age, being a doctor, higher COVID-19 exposure risk, do not know where to seek help, inability to handle stress, poorer sleep quality score, higher total COVID-19 fear score, higher total stress score, and lower total BRS score. The determinants of work-related burnout were younger age, being a doctor, longer years of working, higher COVID-19 exposure risk, do not know where to seek help, lower altruistic score, poorer sleep quality score, higher total stress score, and lower total brief resilience score (BRS) score. The determinants of client-related burnout were doctor, single/divorced, more than one attachment site, and higher satisfaction toward the infection control, inability to handle stress, higher total depression score, and lower total BRS score. CONCLUSION: Every fourth out of ten suffered from personal burnout, one-third from work-related burnout, and one-seventh from client-related burnout among healthcare providers during the COVID-19 pandemic. Healthcare systems must take care of healthcare workers' physical and emotional depletion, reducing the risk of burnout.

Prevalence and factors associated with probable obstructive sleep apnea among patients with hypertension in two primary care clinics in Miri, Sarawak, Malaysia.

PURPOSE: Obstructive sleep apnea (OSA) has been increasingly recognized as an important factor contributing to medical morbidity and mortality. It was reported that more than half of the population with hypertension had OSA. Limited studies have been done on assessing OSA in hypertensive patients. This study aimed to determine the prevalence, socio-demographic characteristics, and factors associated with probable OSA in hypertensive patients in primary care clinics in Sarawak. METHODS: A cross-sectional study was carried out using a systematic random sampling method in hypertensive patients who attended two government primary care clinics in Sarawak. The STOP-Bang questionnaire was used to screen for OSA, and social-demographic data was captured with a questionnaire. Multiple logistic regressions were used to examine the determinants of the OSA. RESULTS: A total of 410 patients were enrolled in this study. The mean age of study population patients was 56.4 years, with more than half being female. The mean blood pressure was 136/82. The prevalence of probable OSA among patients with hypertension was 54.4%. According to multiple logistic regression analyses, smoking (odds ratio [OR] 14.37, 95% confidence interval [CI] 3.335-61.947), retirees (OR 3.20, 95% CI 1.675-6.113), and being Chinese (OR 2.21, 95% CI 1.262-3.863) had a significant positive association with probable OSA. CONCLUSIONS: Because of the high prevalence of probable OSA among patients with hypertension, primary care physicians should be more vigilant in identifying hypertensive patients with OSA risk. Early detection and intervention would reduce disease complications and healthcare costs.

Association between Conversion to Shockable Rhythms and Survival with Favorable Neurological Outcomes for Out-of-Hospital Cardiac Arrests.

BACKGROUND: The initial cardiac rhythm in out-of-hospital cardiac arrest (OHCA) portends different prognoses and affects treatment decisions. Initial shockable rhythms are associated with good survival and neurological outcomes but there is conflicting evidence for those who initially present with non-shockable rhythms. The aim of this study is to evaluate if OHCA with conversion from non-shockable (i.e., asystole and pulseless electrical activity) rhythms to shockable rhythms compared to OHCA remaining in non-shockable rhythms is associated with better survival and neurological outcomes. METHOD: OHCA cases from the Pan-Asian Resuscitation Outcomes Study registry in 13 countries between January 2009 and February 2018 were retrospectively analyzed. Cases with missing initial rhythms, age <18 years, presumed non-medical cause of arrest, and not conveyed by emergency medical services were excluded. Multivariable logistic regression analysis was performed to evaluate the relationship between initial and subsequent shockable rhythm, survival to discharge, and survival with favorable neurological outcomes (cerebral performance category 1 or 2). RESULTS: Of the 116,387 cases included. 11,153 (9.6%) had initial shockable rhythms and 9,765 (8.4%) subsequently converted to shockable rhythms. Japan had the lowest proportion of OHCA patients with initial shockable rhythms (7.3%). For OHCA with initial shockable rhythm, the adjusted odds ratios (aOR) for survival and good neurological outcomes were 8.11 (95% confidence interval [CI] 7.62-8.63) and 15.4 (95%CI 14.1-16.8) respectively. For OHCA that converted from initial non-shockable to shockable rhythms, the aORs for survival and good neurological outcomes were 1.23 (95%CI 1.10-1.37) and 1.61 (95%CI 1.35-1.91) respectively. The aORs for survival and good neurological outcomes were 1.48 (95%CI 1.22-1.79) and 1.92 (95%CI 1.3 - 2.84) respectively for initial asystole, while the aOR for survival in initial pulseless electrical activity patients was 0.83 (95%CI 0.71-0.98). Prehospital adrenaline administration had the highest aOR (2.05, 95%CI 1.93-2.18) for conversion to shockable rhythm. CONCLUSION: In this ambidirectional cohort study, conversion from non-shockable to shockable rhythm was associated with improved survival and neurologic outcomes compared to rhythms that continued to be non-shockable. Continued advanced resuscitation may be beneficial for OHCA with subsequent conversion to shockable rhythms.

Effect of intraoperative hand-grip position on surgical outcome of thumb carpometacarpal arthrodesis.

BACKGROUND: A variety of surgical techniques had been developed over the past few decades for treating thumb carpometacarpal joint (CMCJ) osteoarthritis (OA). However, there are currently no accepted consensus on the ideal treatment for thumb CMCJ OA. Arthrodesis was one of the widely popular treatment methods; however, studies have showed that non-union rates were as high as 50%, with higher complications such as osteoarthritis of neighbouring joints and higher revision surgeries required as compared to other surgical methods. Patients with arthrodesis were also reported to have decreased thumb range of motion and loss of opponens function. Currently, there are numerous intraoperative positioning techniques for arthrodesis which could be confusing for young surgeons. With recent developments of fixation plates and better understanding of the wrist anatomy, this retrospective review aimed to evaluate the efficacy of our intraoperative hand-grip positioning method for arthrodesis of thumb CMCJ OA. What are the postoperative functional outcomes of (1) T-hook plates and (2) our intraoperative hand-grip positioning method for Eaton III thumb CMCJ OA arthrodesis by evaluating pain visual analogue scale (VAS) score, Disabilities of the Arm, Shoulder and Hand questionnaires (DASH), Mayo Wrist scores, capability of thumb opposition (Kapandji score), and comparing pre- and postoperative grip and pinch strength? METHODS: Twenty patients with CMCJ OA underwent arthrodesis using our intraoperative hand-grip positioning method and T-hook plates and screws (Acumed, USA). Patients were evaluated preoperatively and at 1, 3, 6 and 12 months postoperatively. Radiologic assessment including fusion evaluation, evaluation of radial and palmar abduction angles was done on hand X-rays. RESULTS: Twenty patients with a minimum follow-up duration of 12 months were included in this study. 100% fusion rate was achieved with only 1 case of complication involving radial sensory nerve neuropathy which was resolved after removal of implant and neurolysis. Significant improvement in pain and Mayo Wrist scores were noted 3 months postoperatively, whilst DASH score exhibited significant improvements after 6 months of follow-up (p < 0.05). Even though there were no significant differences observed between preoperative and postoperative grip strength, pinch strength and Kapandji scores, positive recovery trends were noted for all parameters with these functions surpassing preoperative levels after 12 months of follow-up. Significant improvements on hand X-rays were also noted for both postoperative radial and palmar abduction angles. CONCLUSIONS: There is currently no consensus on the ideal treatment method for thumb CMCJ OA. In this study, we would like to propose a simple intraoperative hand-grip positioning method with T-hook plates for arthrodesis. As seen from our results, our technique was able to provide satisfactory and replicable postoperative results and thus we would like to propose our hand-grip positioning method with T-hook plates fixation for subsequent treatment of patients with Eaton stage III thumb CMCJ OA.

Monochorionic twin pregnancy in a patient with type III osteogenesis imperfecta: a multidisciplinary challenge.

A woman with severe type III osteogenesis imperfecta spontaneously conceived a monochorionic, diamniotic twin pregnancy. Due to the severity of her condition, her pregnancy required close follow-up involving a multidisciplinary team, including high-risk obstetricians, anaesthetists, pulmonologists and respiratory therapists. Eventually, the twins were delivered via caesarean section at 26 weeks' gestation.We discuss the challenges and considerations in managing her high-risk pregnancy, highlighting the importance of multidisciplinary care in achieving a safe outcome for mother and babies.