2023 clinical practice guidelines on autism spectrum disorder in children and adolescents in Singapore.

Introduction: Autism is a neurodevelopmental condition that is increasing in prevalence worldwide. There has been an exponential increase in autism-related research since 2010, when the first Singapore Clinical Practice Guidelines (CPG) on autism was published. Understanding of autism has since evolved to adopt a lifespan approach beyond that of a childhood condition. The aim of this CPG was to provide an updated set of recommendations for children and adolescents to aid clinical practice for professionals. Method: A multidisciplinary workgroup that comprised representatives from various sectors worked on this CPG. Clinical questions were organised into 10 different sections, each with its own subgroup of members. Seventeen existing international guidelines were evaluated using the Appraisal of Guidelines for REsearch & Evaluation II (AGREE-II) framework, of which 4 met criteria to act as references. Literature review across multiple databases was conducted between January 2011 to 2023; Grading of Recommendations, Assessment, Development and Evaluation (GRADE-like) methodology was used to synthesise evidence. Recommendation statements were derived, following Delphi-style consensus surveys among the workgroup. The draft guidelines underwent external review and public consultation before being formalised. Results: Recommendation and good practice statements pertaining to care of children and adolescents on the autism spectrum across 10 different sections were developed. Evidence matrices complement these recommendations and detail relevant evidence behind each recommendation statement. Conclusion: It is intended for these guidelines to promote effective management and healthcare services for children and adolescents on the autism spectrum, by reinforcing good and evidence-based clinical practice within our national context.

Piperacillin/tazobactam for surgical prophylaxis during pancreatoduodenectomy: meta-analysis.

BACKGROUND: Pancreatoduodenectomy is associated with an increased incidence of surgical-site infections, often leading to a significant rise in morbidity and mortality. This trend underlines the inadequacy of traditional antibiotic prophylaxis strategies. Hence, the aim of this meta-analysis was to assess the outcomes of antimicrobial prophylaxis, comparing piperacillin/tazobactam with traditional antibiotics. METHODS: Upon registering in PROSPERO, the international prospective register of systematic reviews (CRD42023479100), a systematic search of various databases was conducted over the interval 2000-2023. This inclusive search encompassed a wide range of study types, including prospective and retrospective cohorts and RCTs. The subsequent data analysis was carried out utilizing RevMan 5.4. RESULTS: A total of eight studies involving 2382 patients who underwent pancreatoduodenectomy and received either piperacillin/tazobactam (1196 patients) or traditional antibiotics (1186 patients) as antibiotic prophylaxis during surgery were included in the meta-analysis. Patients in the piperacillin/tazobactam group had significantly reduced incidences of surgical-site infections (OR 0.43 (95% c.i. 0.30 to 0.62); P < 0.00001) and major surgical complications (Clavien-Dindo grade greater than or equal to III) (OR 0.61 (95% c.i. 0.45 to 0.81); P = 0.0008). Subgroup analysis of surgical-site infections highlighted significantly reduced incidences of superficial surgical-site infections (OR 0.34 (95% c.i. 0.14 to 0.84); P = 0.02) and organ/space surgical-site infections (OR 0.47 (95% c.i. 0.28 to 0.78); P = 0.004) in the piperacillin/tazobactam group. Further, the analysis demonstrated significantly lower incidences of clinically relevant postoperative pancreatic fistulas (grades B and C) (OR 0.67 (95% c.i. 0.53 to 0.83); P = 0.0003) and mortality (OR 0.51 (95% c.i. 0.28 to 0.91); P = 0.02) in the piperacillin/tazobactam group. CONCLUSION: Piperacillin/tazobactam as antimicrobial prophylaxis significantly lowers the risk of postoperative surgical-site infections, major surgical complications (complications classified as Clavien-Dindo grade greater than or equal to III), clinically relevant postoperative pancreatic fistulas (grades B and C), and mortality, hence supporting the implementation of piperacillin/tazobactam for surgical prophylaxis in current practice.

Meta-analytic connectivity modelling of functional magnetic resonance imaging studies in autism spectrum disorders.

Social and non-social deficits in autism spectrum disorders (ASD) persist into adulthood and may share common regions of aberrant neural activations. The current meta-analysis investigated activation differences between ASD and neurotypical controls irrespective of task type. Activation likelihood estimation meta-analyses were performed to examine consistent hypo-activated and/or hyper-activated regions for all tasks combined, and for social and non-social tasks separately; meta-analytic connectivity modelling and behavioral/paradigm analyses were performed to examine co-activated regions and associated behaviors. One hundred studies (mean age range = 18-41 years) were included. For all tasks combined, the ASD group showed significant (p < .05) hypo-activation in one cluster around the left amygdala (peak - 26, -2, -20, volume = 1336 mm3, maximum ALE = 0.0327), and this cluster co-activated with two other clusters around the right cerebellum (peak 42, -56, -22, volume = 2560mm3, maximum ALE = 0.049) Lobule VI/Crus I and the left fusiform gyrus (BA47) (peak - 42, -46, -18, volume = 1616 mm3, maximum ALE = 0.046) and left cerebellum (peak - 42, -58, -20, volume = 1616mm3, maximum ALE = 0.033) Lobule VI/Crus I. While the left amygdala was associated with negative emotion (fear) (z = 3.047), the left fusiform gyrus/cerebellum Lobule VI/Crus I cluster was associated with language semantics (z = 3.724) and action observation (z = 3.077). These findings highlight the left amygdala as a region consistently hypo-activated in ASD and suggest the potential involvement of fusiform gyrus and cerebellum in social cognition in ASD. Future research should further elucidate if and how amygdala-fusiform/cerebellar connectivity relates to social and non-social cognition in adults with ASD.

Reprint of Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

A 48-Year-Old Immunocompetent Female Resident of Southern Florida with Confirmed Reinfection with P.1 (Gamma) Variant of SARS-CoV-2.

BACKGROUND During the global Coronavirus Disease-2019 (COVID-19) pandemic, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have identified and monitored variants of concerns (VOCs) of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). P.1 (Gamma) variant was initially identified in northern Brazil but has now spread worldwide. This is a report of a 48-year-old female resident of southern Florida with confirmed reinfection with P.1 variant 9 months following the initial infection. This patient was not immunocompromised and was not vaccinated. CASE REPORT A 48-year-old woman residing in southern Florida presented with symptoms of COVID-19 and tested positive for SARS-CoV-2 with oral swab polymerase chain reaction (PCR) in September 2020. Her symptoms resolved spontaneously after 5 days. Nine months later, the patient again presented with respiratory, digestive, and constitutional symptoms. The nasopharyngeal swab SARS-CoV-2 PCR was positive. At that time, she had not received any vaccinations against SARS-CoV-2. Whole-genome sequencing (WGS) of viral RNA from the patient's second infection confirmed that the viral strain was P.1 variant containing the E484K spike protein substitution. CONCLUSIONS This report has identified a confirmed case of reinfection with P.1 variant of SARS-CoV-2 outside Brazil. This case supports recent epidemiological findings that indicate this VOC may have increased infectivity and virulence, and highlights the importance of SARS-CoV-2 vaccination for everyone.

Implementation of a pharmacist-led ARVSP in an academic hospital to reduce ART errors.

OBJECTIVES: The primary objective was to compare the percentage of Antiretroviral Therapy (ART) uncorrected errors during hospital admission before and after the implementation of an Antiretroviral Stewardship Program (ARVSP). PRACTICE DESCRIPTION: This was a 2-year single-center, pre-post quality improvement study. Included in the study were admitted patients at least 18 years of age, diagnosed with human immunodeficiency virus (HIV), and taking at least 1 antiretroviral. The baseline percentage of uncorrected ARV errors was retrospectively determined during the first year. The second year consisted of implementing an ARVSP that prospectively audited ART orders. The ARVSP consisted of a pharmacy resident, a medical resident, an infectious disease, HIV trained pharmacist, an infectious disease physician, and ancillary health care providers. The impact of the ARVSP was assessed by comparing the percentage of uncorrected errors between the 2 time periods. RESULTS: The number of uncorrected errors were 64.1% versus 31.1% before and after ARVSP implementation, respectively (P < 0.05). Delay in therapy errors were statistically significantly reduced (30.1% vs. 22.2%; P < 0.05). The time to overall correction of any error before ARVSP was 3.1 days, and after ARVSP, it was 1.8 days (P = 0.11). CONCLUSION: Implementation of an ARVSP reduces the number of uncorrected antiretroviral-related errors. Because health care resources are finite and focused on the acute care of hospitalized patients, this multidisciplinary practice model may provide a practical approach for similar institutions to improve antiretroviral stewardship surveillance in the inpatient setting.

Meropenem-Resistant Pandoraea Pneumonia in a Critically Ill Patient With COVID-19.

Among patients infected with respiratory viruses, primary coinfection or secondary bacterial pneumonia is common in the severely ill. Pandoraea are multi-drug resistant gram-negative bacilli that have been newly classified in the past 20 years. We present the first reported case of Pandoraea co-infection with SARS-CoV-2 infection. A critically ill gentleman with COVID-19 in acute respiratory distress syndrome (ARDS) requiring mechanical ventilation developed ventilator-associated bacterial pneumonia (VAP). Initial sputum cultures grew Pandoraea species, with subsequent cultures growing P. aeruginosa, and K. pneumoniae as well. The patient failed to improve despite several antibiotic regimens including meropenem. Send-out reference laboratory testing of the Pandoraea species showed susceptibility to amikacin, ciprofloxacin, levofloxacin, imipenem, and minocycline, but resistance to aztreonam, cefepime, ceftazidime, and meropenem. The patient had deteriorated to multi-organ failure by the time minocycline was initiated, and his family had transitioned him into hospice care. Carbapenems are vital agents in the treatment of VAP. Pandoraea species are often resistant to meropenem but often retain in-vitro sensitivity to imipenem-cilastin. Although mainly isolated from respiratory specimens of patients with cystic fibrosis, cases of infection in non-cystic fibrosis patients have been increasingly recognized. The presentation of this case aims to increase awareness of the high drug resistance of this rising species and reduce delays in treatment, especially in COVID-19 coinfection.

Validation of the Child Behavior Rating Scale (CBRS) using multilevel factor analysis.

Behavioral regulation supports children to control their cognitive and emotional skills and participate fully in classroom learning and interactions. Teacher ratings are frequently used to collect data but are highly susceptible to the teacher's response bias, meaning much child level variance is attributable to the teacher level. Multilevel modeling techniques are commonly used to assess the psychometric properties of measures at different levels by disaggregating within- and between-teacher variation in student behaviors. In this study, we attempt to identify the factor structure at each level using teacher ratings on the Child Behavior Rating Scale (CBRS). The sample of 1,375 preschool children (49.2% males) was drawn from a longitudinal study in Singapore. The teacher ratings of these children were collected at three time points (average age at Time 1 was 58.5 months, Time 2 was 69.8 months, and Time 3 was 80.9 months). Using multilevel exploratory and confirmatory factor analyses, a three-factor model at the within level and a two-factor model at the between level best fit the data. At the within level, the three factors were identified as basic interpersonal skills, advanced interpersonal skills, and learning-related social skills. The three factors showed good internal consistency and differential correlates. The two factors at the between level may be related to teacher and classroom characteristics. This study provides empirical support for (a) differential factor structures of CBRS at the within and between levels; and (b) two distinct interpersonal skills. Future studies should aim at exploring the sources of between level variability. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Construct validity of the Family Outcomes Survey - Revised expanded helpfulness scale.

BACKGROUND: With family centred practice as one of the tenets in early childhood intervention (ECI), it is important to understand family outcomes as a means of assessing the effectiveness of ECI services. AIMS: The present paper investigates the psychometric properties of an expanded measure of caregivers' perceptions of helpfulness of ECI services, the Family Outcomes Survey - Revised, Expanded Part B (FOS-RE B). METHODS AND PROCEDURES: Two-hundred and forty-six caregivers of children enrolled in an ECI programme in Singapore completed the FOS-RE B, as well as convergent validity measures (FOS-R Part A, Depression, Stress and Anxiety Scale and questions addressing perceptions of family situation and optimism for the child's future). Confirmatory factor analysis was used to examine the factor structure of the FOS-RE B and correlations were used to examine convergent validity. OUTCOMES AND RESULTS: The factor structure of the FOS-RE B was found to mirror the structure of the FOS-R A, as hypothesized. Evidence for convergent validity, in the form of correlations with family well-being measures was found, as well as evidence for good internal consistency reliability. CONCLUSIONS AND IMPLICATIONS: It is concluded that the FOS-RE B presents a promising measure of perceived helpfulness of ECI services.

Adults with autism spectrum disorders: a review of outcomes, social attainment, and interventions.

PURPOSE OF REVIEW: With the increasing incidence of individuals diagnosed with autism spectrum disorders, there is a need to develop programs to support them throughout their lifespan but research in adulthood support is still scarce. This article aims to provide an up-to-date review of the research on the core characteristics of autism spectrum disorder (ASD), social attainments, and efforts to improve their outcomes. RECENT FINDINGS: The core social communication impairments continue into adulthood among persons with ASD, but the restrictive, repetitive patterns of behavior and activities have received less attention. Adults with ASD experience more behavioral and emotional regulation issues than their peers. In terms of social attainments, adults with ASD have a greater tendency to be overeducated for their jobs and have a lower employment rate. They are also more likely to live with their parents. Interventions make a positive impact upon social communication skills and employment. SUMMARY: Future research could focus on the repetitive behavior of adults with ASD. Likewise, interventions examining the extent to which repetitive behavior and interests can be managed, as well as the degree to which they can be supported in their community access, living arrangements, as well as family quality of life can be further conducted.

Anxiety symptoms in young people with autism spectrum disorder attending special schools: Associations with gender, adaptive functioning and autism symptomatology.

Anxiety-related problems are among the most frequently reported mental health difficulties in autism spectrum disorder. As most research has focused on clinical samples or high-functioning children with autism spectrum disorder, less is known about the factors associated with anxiety in community samples across the ability range. This cross-sectional study examined the association of gender, age, adaptive functioning and autism symptom severity with different caregiver-reported anxiety symptoms. Participants were caregivers of 241 children (6-18 years old) with autism spectrum disorder attending special schools in Singapore. Measures included the Spence Children's Anxiety Scale and assessments of overall emotional, behavioural and adaptive functioning. Caregivers reported more anxiety symptoms in total, but fewer social anxiety symptoms, than Spence Children's Anxiety Scale Australian/Dutch norms. There were no gender differences. Variance in total anxiety scores was best explained by severity of repetitive speech/stereotyped behaviour symptoms, followed by adaptive functioning. Severity of repetitive speech/behaviour symptoms was a significant predictor of separation anxiety, generalized anxiety, panic/agoraphobia and obsessive-compulsive subscale symptoms, but not of social phobia and physical injury fears. Adaptive functioning and chronological age predicted social phobia and generalized anxiety symptoms only. Severity of social/communication autism symptoms did not explain any anxiety symptoms, when the other variables were controlled for. Findings are discussed in relation to the existing literature. Limitations and possible implications for prevention, assessment and intervention are also discussed.

Psychometric validation of the Family Outcome Survey-Revised in Singapore.

This study sought to examine the construct validity of the Family Outcomes Survey-Revised (FOS-R) in Singapore, describe the extent to which family outcomes of early childhood intervention (ECI) are attained, and obtain caregivers' perception on the extent to which ECI has served their needs. The FOS-R was translated into Chinese (simplified) and Malay for use in Singapore. Bilingual (i.e., English-Chinese and English-Malay) versions of the instrument were distributed to caregivers of young children with disabilities receiving ECI in four centers in Singapore. A total of 291 surveys were available for analyses (response rate of 43.1%). Confirmatory factor analyses indicated that there was a fit between the current data set and the FOS-R structure proposed by the developers. Overall, the participants reported moderately high attainment of family outcomes. They also reported that the ECI programs were mostly helpful. Other aspects of the cross-cultural application of instruments were considered and implications for local service provision as well as directions for future research were discussed.

Treatment outcomes in undocumented Hispanic immigrants with HIV infection.

OBJECTIVE: Little is known about the treatment outcomes of undocumented Hispanic immigrants with HIV infection. We sought to compare the treatment outcomes of undocumented and documented patients 12-months after entering HIV care. METHODS: We conducted a retrospective cohort study of antiretroviral-naive patients 18 years and older attending their first visit at Thomas Street Health Center in Houston, Texas, between 1/1/2003 and 6/30/2008. The study population of 1,620 HIV-infected adults included 186 undocumented Hispanic, 278 documented Hispanic, 986 Black, and 170 White patients. The main outcome measures were retention in care (quarter years with at least one completed HIV primary care provider visit) and HIV suppression (HIV RNA <400 copies/mL), both measured 12-months after entering HIV care. RESULTS: Undocumented Hispanic patients had lower median initial CD4 cell count (132 cells/mm(3)) than documented Hispanic patients (166 cells/mm(3); P = 0.186), Black patients (226 cells/mm(3); P<0.001), and White patients (264 cells/mm(3); P = 0.001). However, once in care, undocumented Hispanic patients did as well or better than their documented counterparts. One year after entering HIV care, undocumented Hispanics achieved similar rates of retention in care and HIV suppression as documented Hispanic and White patients. Of note, black patients were significantly less likely to have optimal retention in care (adjusted odds ratio [aOR] 0.65, CI = 0.45-0.94) or achieve HIV suppression (aOR 0.32, CI = 0.17-0.61) than undocumented Hispanics. CONCLUSIONS: Undocumented Hispanic persons with HIV infection enter care with more advanced disease than documented persons, suggesting testing and/or linkage to care efforts for this difficult-to-reach population need intensification. Once diagnosed, however, undocumented Hispanics have outcomes as good as or better than other racial/ethnic groups. Safety net providers for undocumented immigrants are vital for maintaining individual and public health.

Parental expectations regarding postschool social attainments of adolescents with autism spectrum disorders in Singapore.

This study sought to understand the parental expectations of social attainments in the postschool years. The parents of 20 adolescents with autism spectrum disorders (ASD) attending special schools were interviewed. Most expected their children would be working in sheltered workshops or unemployed. All parents indicated that their children would live with them until they were unable to provide appropriate care, and nearly half expressed wishes for relatives to care for them thereafter. None expected any independent access to the community. Analysis of the interviews suggested that the adolescents' learning and behavior, parental concerns, availability of formal resources, and societal factors influenced parents' expectations. Implications for working with Asian populations and for service delivery in Singapore are discussed.

To what extent do joint attention, imitation, and object play behaviors in infancy predict later communication and intellectual functioning in ASD?

The extent to which early social communication behaviors predict later communication and intellectual outcomes was investigated via retrospective video analysis. Joint attention, imitation, and complex object play behaviors were coded from edited home videos featuring scenes of 29 children with ASD at 9-12 and/or 15-18 months. A quantitative interval recording of behavior and a qualitative rating of the developmental level were applied. Social communication behaviors increased between 9-12 and 15-18 months. Their mean level during infancy, but not the rate of change, predicted both Vineland Communication scores and intellectual functioning at 3-7 years. The two methods of measurement yielded similar results. Thus, early social communicative behaviors may play pivotal roles in the development of subsequent communication and intellectual functioning.

Challenging behaviors among children with autism spectrum disorders and multiple disabilities attending special schools in Singapore.

This study sought to understand the profile of and the factors which impact upon challenging behaviors among children with autism spectrum disorders (ASD) and multiple disabilities (MD). Teachers of 322 and 132 children with ASD and MD, respectively, attending special schools in Singapore, completed the Developmental Behavior Checklist, Teacher Version (DBC-T; Einfeld & Tonge, 1995). The findings suggest that children with ASD exhibit elevated levels of challenging behavior in all areas, relative to children with MD. Multiple regression analyses also indicate that diagnostic category was associated with all aspects of challenging behavior measured by the DBC-T. In addition, age was associated with only disruptive/antisocial behaviors in this study. Theoretical and practical implications were discussed.

Long-term results of surgical techniques and procedures in men with benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is one of the most common conditions associated with the aging male. Surgical management of lower urinary tract symptoms attributed to BPH has progressed over time as urologic surgeons search for more innovative and less invasive forms of treatment. Transurethral resection of the prostate (TURP) has long been the "gold standard" to which all other forms of treatment are compared. There are several different methods of surgical treatment of BPH, including whole gland enucleation/intact removal, vaporization, and induction of necrosis with delayed reabsorption as well as hybrid techniques. As with any form of surgical intervention, long-term results define success. Long-term follow-up consists of examining overall efficacy with attention to associated adverse events. TURP has the luxury of the longest follow-up, while less invasive forms of treatment starting to acquire long-term data. There are several surgical options for BPH; newer methods do show promise, while the "gold standard" continues to demonstrate excellent surgical results.

The perception of social situations by children with autism spectrum disorders.

This study investigated how children with autism spectrum disorders (ASD) make social judgments of social situations and provide justifications for their responses. Fifteen children with ASD and 15 typically developing children (ages from 9 to 13 years old) were presented with eight vignettes, based on the Dewey Story Test (Dewey, 1991) and developed for the purposes of this study. The participants rated the appropriateness (on a 4-point Likert scale) of the socially inappropriate event (test item) and non-social appropriate event (control item) in each vignette. Justifications for each rating were also elicited at the end of each vignette. The children with ASD rated socially inappropriate behaviors in vignettes no differently from their typically developing peers but rated control items as stranger. They also had a higher tendency to provide inappropriate/bizarre and don't know/no response justifications instead of appropriate/social justifications (that reflect social awareness). The impact of the method of eliciting social judgments of social situations and its impact on findings are discussed.

Dietary patterns, supplement use, and the risk of benign prostatic hyperplasia.

It has long been appreciated that a healthy lifestyle plays a critical role in cardiovascular health. It is now apparent that the same is true in the development of benign prostatic hyperplasia (BPH). Prospective cohort data originating from recently published randomized trials on the medical treatment of BPH and prevention of prostate cancer have been invaluable. A growing body of evidence suggests that exercise and the intake of specific macronutrients and micronutrients through regular diet play a beneficial role. Most strikingly, the magnitude of these effects is similar to medical therapies using alpha-blockers and 5-alpha-reductase inhibitors. The use of supplements for prostate disease is a multibillion dollar business in the United States, and supplements are more commonly prescribed than medical therapy in many countries. In contrast to consumption of micronutrients through regular diet, supplemental intake of micronutrients and phytotherapies currently lack evidence to support their efficacy.