Factors Associated With Successful Surgical Exposure of Impacted Maxillary Canines.

PURPOSE: Impacted maxillary canines occur in up to 3% of the population and their eruption is of great importance in establishing, maintaining the shape, aesthetics, and function of the dental arch. Hence, surgical exposure of canines for the purpose of aligning them is a common surgical procedure. This study identifies the frequency and the statistically significant factors associated with successful surgical exposure of impacted maxillary canines and the relative risk factors for repeat surgery. METHODS: This is a retrospective cohort study of 182 patients who underwent surgical exposure of impacted maxillary canines and orthodontic alignment, over a 5-year period between 2014 and 2018. The variables recorded and analyzed included demographics (age and gender), type of surgery (closed or open exposure), grade of surgeon, and radiographic features on orthopantomogram (canine overlap of adjacent tooth root, vertical canine crown height, canine angulation to midline, position of canine root apex). Outcome data recorded were successful surgical exposure and orthodontic alignment and the need for repeat operation or surgical removal due to ankylosis. The data were analyzed to identify the statistically significant correlates of successful surgical exposure and the relative risk factors associated with repeat surgery. RESULTS: A total of 182 patients and 232 bone-impacted maxillary surgical canine exposures were analyzed, as 50 patients had bilateral impaction. Mean age was 15 years (range = 10-38 years), with 122 (67%) female to 60 (33%) male ratio. Total of 222/232 (96%) impacted maxillary canine teeth were successfully surgically exposed and 10/232 (4%) required re-exposure surgery. Correlates of successful surgical exposures were open exposure technique (P < .002) and reduced distance of vertical canine crown height from alveolar bone margin (P < .033). Relative risk factors for repeat surgery were increased age, male, closed surgical exposure, grade of surgeon, central impaction, increased overlap of adjacent root, increased vertical height, increased angulation to midline, canine apex position above second premolar and procedure done under local anesthetics. CONCLUSIONS: This is the largest impacted maxillary canine study to date which has identified the factors that result in successful surgical exposure, hence allow selection of the patients most suitable for this treatment. Secondly, patients with relative risk factors for repeat surgical intervention may be consented appropriately, triaged for a closer orthodontic follow-up and prioritized for surgery to reduce overall treatment time.

Cerebral arterial gas embolism and neurogenic stunned myocardium in a previously healthy freediver.

Cardiomyopathy is a known but rare sequelae of diving-related cerebral arterial gas embolism (CAGE). In previously reported cases, patient findings have been consistent with takotsubo cardiomyopathy (TCM) per the revised Mayo Clinic's diagnostic criteria. A lesser-known variant of stress-related cardiomyopathy is neurogenic stunned myocardium (NSM), which occurs after a neurological event such as subarachnoid hemorrhage and typically presents in younger patients. Presentation tends to differ slightly to TCM with non-specific left ventricular dysfunction and T wave inversions. This case adds to the rare numbers of reported cardiomyopathy from diving and is the first reported case of suspected NSM associated with CAGE.

Mental health awareness of secondary schools students: Mediating roles of knowledge on mental health, knowledge on professional help, and attitude towards mental health.

Purpose: The mental health situation among adolescents in Malaysia has reached a worrying state with the rising number of cases. Despite a significant increase in the literature on mental health, there is a lack of studies that focused on mental health awareness. Therefore, this study aimed to investigate the factors affecting Malaysian youth's mental health awareness as well as the mediating roles of knowledge on mental health, knowledge on professional help, and attitude towards mental health. Methods: Self-administered questionnaires were distributed to 450 secondary school students aged 15-19 years old in Kuala Lumpur and Melaka who were recruited via purposive sampling. Data analysis was performed using SPSS and SmartPLS to obtain the descriptive analysis, measurement model, and structural model. Results: The results indicated that mental health awareness was influenced by knowledge on mental health and attitude towards mental health. The findings also revealed that familiarity and media exposure were important determinants of knowledge on mental health, knowledge on professional help, and attitude towards mental health. Moreover, the results indicated that knowledge on mental health positively mediated the relationship between media exposure and mental health awareness. Besides, attitude towards mental health also found to play mediating roles between familiarity and mental health awareness, as well as between media exposure and mental health awareness. Conclusion: This study contributed important knowledge to the limited literature in this contemporary domain. An effective public mental health campaign is needed to reduce the burden of disease and the cost of mental illness.

Intention towards renewable energy investments in Malaysia: extending theory of planned behaviour.

Renewable energy investments possess great potential for reducing the consumption of fossil fuels influenced by various determinants. This study investigates the individual investors' renewable energy investments' intention within the framework of the theory of planned behaviour (TPB) based on a survey conducted in 3 major states in Malaysia. The results indicate that one's intention to invest in renewable energy investments is influenced by attitude, subjective norm, perceived behavioural control and evaluation of regulatory framework. Risk aversion on the other hand was found to have no effect on investors' intention towards such investments. The findings also reveal that the evaluation of regulatory framework is the most important determinant. This outcome contradicts the outcomes arrived at by the previous studies that focus on investment behaviours or other types of pro-environmentally intention or behaviours. This research also investigates the indirect effects of TPB on explaining investor's intention towards renewable energy investments through the evaluation of regulatory framework. The results indicate that the investors' intention towards renewable energy investments is indirectly influenced by attitude and perceived behavioural control. Subjective norm does not have an indirect effect on investors' intention towards renewable energy investments. This study provides policymakers' important practical implications to improve renewable energy investments.

Pre-Hospital Administration of Opioids in Trauma Patients: Is Dose Associated With Outcomes?

BACKGROUND: Opioids are commonly used as an analgesic agent in the prehospital setting. Current efforts to prevent and control prescription opioid overuse are focused on the in-hospital and post-discharge phases. The aim of our study was to assess the associations between pre-hospital opioids use and in-hospital outcomes among trauma patients. METHODS: We performed a 2 year (2016-2017) retrospective analysis of our Level-I trauma center database. We included all adult trauma patients (age > 18y) who received pre-hospital opioids (Fentanyl (F) or Morphine-Sulfate (MS)). Outcome measures were emergency-department (ED) hypotension (SPB < 90 mmHg), ED intubation, prescription opioid medication upon discharge, and mortality. Multivariate logistic regression was performed. RESULTS: In total, 709 patients were included in the analysis. Cutoff values of 200 mcg F and 15 mg MS were significantly associated with adverse outcomes. Overall, the ED hypotension rate was 14.4%, ED intubation rate was 6%, and ED mortality rate was 3.1%. On regression analysis, higher dosages of both pre-hospital F and pre-hospital MS were independently associated with increased odds of ED hypotension, ED intubation, and discharge on opioid medications, but not with ED mortality. CONCLUSION: Pre-hospital administration of high dose opioids is associated with increased odds of adverse outcomes. Collaborative efforts to standardize and control the overuse of opioids should target the pre-hospital setting to limit opioid associated adverse effects.

Robotic-Assisted Peripheral Nerve Surgery: A Systematic Review.

BACKGROUND: Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future. METHODS: A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared. RESULTS: Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely. CONCLUSION: Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.

Bleeder With a Clot: Thrombosis Following Treatment of Bleeding in a Child With Severe Hemophilia B.

A 16-year-old boy with severe hemophilia B and minimal bleeding manifestations in his early childhood presented with gastrointestinal bleeding at 11 years of age. Following administration of prothrombin complex concentrate, he developed peripheral venous thrombosis and cerebral sinovenous thrombosis, posing a management dilemma. His cerebral sinovenous thrombosis resolved spontaneously, proving watchful waiting to be a useful strategy. He developed spontaneous intracranial bleed at 14 years of age for which he was treated with factor IX concentrate and commenced on prophylaxis. We discuss the factors contributing to genotype-phenotype dissonance in severe hemophilia and considerations before commencing prophylaxis in such cases.

International Microsurgery Club: An Effective Online Collaboration System.

BACKGROUND: This study aimed to determine if International Microsurgery Club (IMC) is an effective online resource for microsurgeons worldwide, in providing an avenue for timely group discussions and advice regarding complicated cases, and an avenue for collaboration and information sharing. METHODS: All posts on the IMC Facebook group from member 1 to 8,000 were analyzed according to inclusion criteria and categorized into three categories-case discussion, question, and information sharing. Posts were retrospectively analyzed for number of responses, time of responses, number of "likes," number of treatment options, time of day, and demographics of authors and responders. RESULTS: A retrospective analysis of 531 cases showed an average response rate of 75.7% within 1 hour and as membership grew. The response rate stabilized averaging between 72.5 and 78% across all times of the day. An average of 11.8 microsurgeons was involved per case discussion, and 5.7 treatment options were provided per case. CONCLUSION: IMC is shown to be an effective resource to allow microsurgeons to access timely advice from other microsurgeons without time and distance limitation, and to have interactive group discussions on complicated cases.

Gratitude inhibits competitive behaviour in threatening interactions.

It is well established that gratitude favours prosocial tendencies in neutral and amicable social interactions. Less is clear, however, about the role of gratitude in threatening situations that breed competitive impulses. As gratitude inhibits self-centred impulses and motivates a communal orientation, we predict and demonstrate that gratitude reduces competitive behaviour in threatening interactions. In Study 1 (N = 171), after emotion induction, participants went through the classic Trucking game paradigm, whereby a bogus opponent behaved in a competitive manner (i.e. closing the gate on them). Gratitude, as compared to joy and a neutral mood state, reduced participants' competitive behaviour against the opponent. In Study 2 (N = 422), after losing to a bogus opponent on a self-relevant task, participants were given an opportunity to sabotage the opponent's chances of winning a lottery. Individuals induced to feel gratitude showed less sabotaging behaviour than those in a neutral mood state. Importantly, this effect was only observed against a highly competitive, but not a neutral, opponent, suggesting that gratitude inhibits competitive behaviour only under high threat. Our findings suggest that gratitude is instrumental in arresting the competitive cycles from developing in threatening social interactions.

The global burden of sickle cell disease in children under five years of age: a systematic review and meta-analysis.

BACKGROUND: Sickle cell disease (SCD) is a common haematological disorder, affecting millions of people worldwide. It is most prevalent in malarial endemic areas in the tropics where outcomes are often poor due to resource constraints, resulting in most children dying before reaching adulthood. As increasing progress is made towards reducing under 5 mortality from infectious causes, non-communicable diseases (NCDs) including SCD have risen to the forefront of the global health agenda. Despite this, the global mortality burden of SCD remains poorly understood. This study aimed to estimate the incidence and mortality of SCD in children under 5 years of age in order to inform policy and develop sustainable strategies to improve outcomes. METHODOLOGY: We performed a systematic literature search of Medline, EMBASE, Journals@Ovid, and Web of Science for studies on the incidence and mortality of SCD in children under 5, with search dates set from January 1980 and July 2017. We conducted random effects meta-analysis to obtain pooled meta-estimates of birth prevalence and mortality rates globally, and for each World Health Organization (WHO) region. RESULTS: 67 papers were found with relevant data. 52 contained data on incidence and prevalence and 15 contained data on mortality. The overall pooled estimate of mortality from the limited data available was 0.64 per 100 years of child observation (95% CI = 0.28-1.00) with the highest rate seen in Africa 7.3 (95% CI = 4.03-10.57). The global meta-estimate for the birth prevalence of homozygous sickle cell disease was 112 per 100 000 live births (95% CI = 101-123) with a birth prevalence in Africa of 1125 per 100 000 (95% CI = 680.43-1570.54) compared with 43.12 per 100 000 (95% CI = 30.31-55.92) in Europe. CONCLUSION: There were a number of limitations in the depth and breadth of available data however it is clear that both the highest prevalence and highest mortality of SCD is in Africa. In order to address this burden, there is a need for national comprehensive newborn screening to identify patients, and the development of holistic SCD care programmes to provide therapeutics and education for families and children with SCD. This targeted funding should form part of a broader increased global focus on NCDs in childhood.

Five-Year Review of Patients Presenting with Non-Accidental Injury to a Children's Emergency Unit in Singapore.

INTRODUCTION: There is an increasing trend of physical child abuse cases reported in Singapore. Children presenting to the Emergency Department with injuries require a high index of suspicion for clinicians to distinguish those that are abusive in nature. MATERIALS AND METHODS: A retrospective study of children with diagnosis of NAI presenting to KK Women's and Children's Hospital (KKH) from June 2011 to May 2016 was conducted. RESULTS: There were 1917 cases reported from 1730 subjects, of  which: 8.8% of subjects had repeat visits; 55.2% of cases were male; and mean age was 7.69 years. Racial demographics were: Chinese 45.5%, Malay 33.4%, Indian 15.4% and Others 5.9%. The most frequent injuries sustained were head and neck (50.8%), limbs (32.2%), and chest (5.7%). Of the type of injuries, 55% had contusions, 21% had cane marks, 16% had lacerations, 4.4% had burn marks and 1% sustained fractures. Males were more likely to be caned (P <0.001); 54.9% of cases were admitted and 38.9% were discharged. Cases that presented without a parent (P <0.001), were known to Child Protective Service (P <0.001), or had a history of  parental substance abuse (P = 0.038), mental illness in caregiver (P = 0.021), or domestic violence (P <0.001) were more likely to require admission. CONCLUSION: Analysing these factors provide a better understanding of  the presentation of  NAI cases, including 'red flags' and vulnerable groups who should have better protection.

Metastatic melanoma of unknown primary in the temporalis muscle.

Melanomas are aggressive cancers that present as cutaneous, mucosal and ocular lesions with the ability to metastasise widely. There are, however, occasions where lesions are found in distant sites such as lymph nodes, viscera and subcutaneous tissues without clinically apparent skin involvement. This is known as metastatic melanoma of unknown primary (MUP). Its presentation in skeletal muscle is rare, and the available literature is sparse. This article presents an 85-year-old woman with a MUP presenting in the right temporalis muscle, which was diagnosed with the aid of the ultrasound-guided core biopsy. The melanoma deposit was successfully excised, and no recurrence was identified. The patient is now under close follow-up.

Ultrasonographic Diagnosis of Thoracic Outlet Syndrome Secondary to Brachial Plexus Piercing Variation.

Structural variations of the thoracic outlet create a unique risk for neurogenic thoracic outlet syndrome (nTOS) that is difficult to diagnose clinically. Common anatomical variations in brachial plexus (BP) branching were recently discovered in which portions of the proximal plexus pierce the anterior scalene. This results in possible impingement of BP nerves within the muscle belly and, therefore, predisposition for nTOS. We hypothesized that some cases of disputed nTOS result from these BP branching variants. We tested the association between BP piercing and nTOS symptoms, and evaluated the capability of ultrasonographic identification of patients with clinically relevant variations. Eighty-two cadaveric necks were first dissected to assess BP variation frequency. In 62.1%, C5, superior trunk, or superior + middle trunks pierced the anterior scalene. Subsequently, 22 student subjects underwent screening with detailed questionnaires, provocative tests, and BP ultrasonography. Twenty-one percent demonstrated atypical BP branching anatomy on ultrasound; of these, 50% reported symptoms consistent with nTOS, significantly higher than subjects with classic BP anatomy (14%). This group, categorized as a typical TOS, would be missed by provocative testing alone. The addition of ultrasonography to nTOS diagnosis, especially for patients with BP branching variation, would allow clinicians to visualize and identify atypical patient anatomy.

Protein interactions of phosphatase and tensin homologue (PTEN) and its cancer-associated G20E mutant compared by using stable isotope labeling by amino acids in cell culture-based parallel affinity purification.

The tumor suppressor PTEN (phosphatase and tensin homologue) negatively regulates the PI3K pathway through its lipid phosphatase activity and is one of the most commonly lost tumor suppressors in human cancers. Though the tumor suppressive function involves the lipid phosphatase-dependent and -independent activities of PTEN, the mechanism leading to the phosphatase-independent function of PTEN is understood poorly. Some PTEN mutants have lipid phosphatase activity but fail to suppress cell growth. Here, we use a cancer-associated mutant, G20E, to gain insight into the phosphatase-independent function of PTEN by investigating protein-protein interactions using MS-based stable isotope labeling by amino acids in cell culture (SILAC). A strategy named parallel affinity purification (PAP) and SILAC has been developed to prioritize interactors and to compare the interactions between wild-type and G20E PTEN. Clustering of the prioritized interactors acquired by the PAP-SILAC approach shows three distinct clusters: 1) wild-type-specific interactors, 2) interactors unique to the G20E mutant, and 3) proteins common to wild-type and mutant. These interactors are involved mainly in cell migration and apoptosis pathways. We further demonstrate that the wild-type-specific interactor, NUDTL16L1, is required for the regulatory function of wild-type PTEN in cell migration. These findings contribute to a better understanding of the mechanisms of the phosphatase-dependent and -independent functions of PTEN.

Eimeria maxima phosphatidylinositol 4-phosphate 5-kinase: locus sequencing, characterization, and cross-phylum comparison.

Phosphatidylinositol 4-phosphate 5-kinase (PIP5K) may play an important role in host-cell invasion by the Eimeria species, protozoan parasites which can cause severe intestinal disease in livestock. Here, we report the structural organization of the PIP5K gene in Eimeria maxima (Weybridge strain). Two E. maxima BAC clones carrying the E. maxima PIP5K (EmPIP5K) coding sequences were selected for shotgun sequencing, yielding a 9.1-kb genomic segment. The EmPIP5K coding region was initially identified using in silico gene-prediction approaches and subsequently confirmed by mapping rapid amplification of cDNA ends and RT-PCR-generated cDNA sequence to its genomic segment. The putative EmPIP5K gene was located at position 710-8036 nt on the complimentary strand and comprised of 23 exons. Alignment of the 1147 amino acid sequence with previously annotated PIP5K proteins from other Apicomplexa species detected three conserved motifs encompassing the kinase core domain, which has been shown by previous protein deletion studies to be necessary for PIP5K protein function. Phylogenetic analysis provided further evidence that the putative EmPIP5K protein is orthologous to that of other Apicomplexa. Subsequent comparative gene structure characterization revealed events of intron loss/gain throughout the evolution of the apicomplexan PIP5K gene. Further scrutiny of the genomic structure revealed a possible trend towards "intron gain" between two of the motif regions. Our findings offer preliminary insights into the structural variations that have occurred during the evolution of the PIP5K locus and may aid in understanding the functional role of this gene in the cellular biology of apicomplexan parasites.

XA27 depends on an amino-terminal signal-anchor-like sequence to localize to the apoplast for resistance to Xanthomonas oryzae pv oryzae.

The rice (Oryza sativa) gene Xa27 confers resistance to Xanthomonas oryzae pv oryzae, the causal agent of bacterial blight disease in rice. Sequence analysis of the deduced XA27 protein provides little or no clue to its mode of action, except that a signal-anchor-like sequence is predicted at the amino (N)-terminal region of XA27. As part of an effort to characterize the biochemical function of XA27, we decided to determine its subcellular localization. Initial studies showed that a functional XA27-green fluorescent protein fusion protein accumulated in vascular elements, the host sites where the bacterial blight pathogens multiply. The localization of XA27-green fluorescent protein to the apoplast was verified by detection of the protein on cell walls of leaf sheath and root cells after plasmolysis. Similarly, XA27-FLAG localizes to xylem vessels and cell walls of xylem parenchyma cells, revealed by immunogold electron microscopy. XA27-FLAG could be secreted from electron-dense vesicles in cytoplasm to the apoplast via exocytosis. The signal-anchor-like sequence has an N-terminal positively charged region including a triple arginine motif followed by a hydrophobic region. Deletion of the hydrophobic region or substitution of the triple arginine motif with glycine or lysine residues abolished the localization of the mutated proteins to the cell wall and impaired the plant's resistance to X. oryzae pv oryzae. These results indicate that XA27 depends on the N-terminal signal-anchor-like sequence to localize to the apoplast and that this localization is important for resistance to X. oryzae pv oryzae.

Role of TAp73alpha in induction of apoptosis by transforming growth factor-beta in gastric cancer cells.

Transforming growth factor-beta (TGF-beta) is implicated as a tumor suppressor because it eliminates cancer cells from normal tissues by inhibiting cell growth and inducing apoptosis. Although p53 tumor suppressor is required for TGF-beta-induced p21 WAF1 expression and cell growth inhibition, its role in TGF-beta-induced apoptosis remains unclear. Here, we report that TAp73alpha, which is a member of the p53 family, binds to p53-binding sites in the promoters of proapoptotic Bax and Puma to activate their transcription, and mediates TGF-beta-induced apoptosis in gastric cancer cells. Our findings reveal a novel role of TAp73alpha in the induction of apoptosis by TGF-beta in cancer cells.

Progression of cognitive impairment after stroke: one year results from a longitudinal study of Singaporean stroke patients.

BACKGROUND AND PURPOSE: Vascular dementia accounts for 40-50% of dementia cases in Singapore. The aim of this study is to examine the prevalence and natural history of cognitive impairment in a cohort of Singaporean post-stroke patients. METHODS: The Vascular Dementia Battery (VDB) was offered to 252 patients with a transient ischaemic attack (TIA) or non-disabling ischaemic stroke at baseline (within 6 months post index stroke) and annually thereafter. The VDB assesses six cognitive domains: attention, language, verbal memory (recall and recognition), visual memory (recall and recognition), visuoconstruction and visuomotor speed. Dementia was diagnosed using the DSM-IV criteria. Patients who did not meet the DSM-IV criteria but were impaired in one or more cognitive domains were classified as 'cognitively impaired but not demented'. Those who were unimpaired in all cognitive domains were classified as 'cognitively intact'. RESULTS: At baseline, 56% of patients were 'cognitively intact', 40% were 'cognitively impaired but not demented' and 4% were 'demented'. At 1-year follow-up, 33% patients had a changed classification from baseline. While 31% of those who were 'cognitively impaired but not demented' at baseline improved to 'cognitively intact', 10% of the 'cognitively intact' group deteriorated to 'cognitively impaired but not demented' and 11% deteriorated from 'cognitively impaired but not demented' to 'demented'. Cognitive performance at baseline predicted for deterioration. CONCLUSIONS: This study suggests that the long-term cognitive performance in stroke patients change over time. Further studies are required to identify risk factors and effective treatment for cognitive deterioration after stroke.