Gender differences in osteoporotic hip fractures in Sarawak General Hospital.

INTRODUCTION: Osteoporosis and osteoporotic fracture pose a major public health problem in our ageing population, and particularly concerning is the increased morbidity and mortality associated with osteoporotic hip fractures. While overall diagnosis and treatment for osteoporosis have improved, osteoporosis in men remains underdiagnosed and undertreated. We aim to describe the difference in clinical characteristics between elderly men and women with osteoporotic hip fractures in Sarawak General Hospital. MATERIALS AND METHODS: All patients diagnosed with osteoporotic hip fracture admitted to Sarawak General Hospital from June 2019 to March 2021 were recruited, and demographic data and clinical features were obtained. RESULTS: There were 140 patients with osteoporotic hip fracture, and 40 were men (28.6%). The mean age for males was 74.1 ± 9.5 years, while the mean age for females was 77.4 ± 9.1 years (p=0.06). The types of fracture consisted of neck of femur=78, intertrochanteric=61 and subtrochanteric=1. More men were active smokers (15% vs 1%, p<0.001). There were 20 men with secondary osteoporosis (50%), while 13 women (13%) had secondary osteoporosis (p<0.001). The causes of secondary osteoporosis among the men were hypogonadism, COPD, glucocorticoid-induced osteoporosis, renal disease, androgen deprivation therapy, thyroid disorder, prostate cancer and previous gastrectomy. There were two deaths among the men and four deaths among the women during the inpatient and 3 months follow-up period. There was no statistical significance between the mortality rates between male patients (5%) and female patients (4%) (p=0.55). CONCLUSION: There were more females with osteoporotic hip fractures, and there were significantly more males with secondary osteoporotic hip fractures.

Development, implementation and initial feasibility testing of the MediEmo mobile application to provide support during medically assisted reproduction.

STUDY QUESTION: Is it possible to develop a patient smartphone application for medically assisted reproduction (MAR) that is acceptable to patients and fertility staff? SUMMARY ANSWER: Staff and patients responded positively to the MediEmo smartphone application, perceiving it to be acceptable and feasible to implement in a busy clinic. WHAT IS KNOWN ALREADY: Digital tools are increasingly popular to provide practical, administrative and psychological support alongside medical treatments. Apps and other digital tools have been developed for use alongside MAR but there is very limited research on the development or acceptability and feasibility of these tools. STUDY DESIGN, SIZE, DURATION: Mixed methods research. This article outlines the development phase of the MediEmo smartphone app, which was guided by the Medical Research Council development framework for complex interventions. The resulting MediEmo app was then implemented into a single centre for MAR in the UK, acceptability evaluated and feasibility explored among 1106 potential participants undertaking IVF cycles. PARTICIPANTS/MATERIALS, SETTING, METHODS: Consultation and data collection took part at a single mid-sized urban fertility clinic. Development of the MediEmo smartphone application took place during 2013 to 2017. Implementation of the MediEmo took place from June 2017 to September 2020. The MediEmo app comprises three functions (six features) namely medication management (medication timeline, messaging), mood management (emotional tracking, coping support) and functional support (frequently asked questions, symptom checker). Data on age, fertility diagnosis, anti-Müllerian hormone level were collected about the users of the MediEmo in addition to MediEmo usage data and attitudes towards the MediEmo smartphone application. MAIN RESULTS AND THE ROLE OF CHANCE: Informed by the developmental process described, MediEmo is an app combining patient medication diary management and ease of integration into clinic systems with emotional support, emotional tracking and data capture. This study demonstrates acceptability and feasibility of MediEmo, with good uptake (79.8%), mood data sensitivity and reliability and positive feedback. LIMITATIONS, REASONS FOR CAUTION: Single centre, small number of users in questionnaire studies. WIDER IMPLICATIONS OF THE FINDINGS: The findings suggest smartphone apps can contribute to fertility care and that patient engagement is high. Evaluation of any apps introduced into clinical pathways should be encouraged to promote development of the most useful digital tools for fertility patients. STUDY FUNDING/COMPETING INTEREST(S): This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. Outside of the submitted work, J.B. reports personal speaker fees from Merck KGaA, Darmstadt, Germany, Merck AB an affiliate of Merck KGaA, Darmstadt Germany, Theramex, MedThink China, Ferring Pharmaceuticals A/S, grant from Merck Serono Ltd, outside the submitted work and that she is co-developer of Fertility Quality of Life (FertiQoL) and MediEmo app; N.M and C.Y are minority shareholders and J.B.'s University (Cardiff University) owns one third of shares. None of the shareholders benefitted financially from MediEmo. I.R., C.H. and K.Y.B.N. declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

PesTrapp mobile app: A trap setting application for real-time entomological field and laboratory study.

Diseases such as malaria, dengue, Zika and chikungunya remain endemic in many countries. Setting and deploying traps to capture the host/vector species are fundamental to understand their density and distributions. Human effort to manage the trap data accurately and timely is an exhaustive endeavour when the study area expands and period prolongs. One stop mobile app to manage and monitor the process of targeted species trapping, from field to laboratory level is still scarce. Toward this end, we developed a new mobile app named "PesTrapp" to acquire the vector density index based on the mobile updates of ovitraps and species information in field and laboratory. This study aimed to highlight the mobile app's development and design, elucidate the practical user experiences of using the app and evaluate the preliminary user assessment of the mobile app. The mobile app was developed using mobile framework and database. User evaluation of the mobile app was based on the adjusted Mobile App Rating Scale and Standardized User Experience Percentile Rank Questionnaire. The process flows of system design and detailed screen layouts were described. The user experiences with and without the app in a project to study Aedes surveillance in six study sites in Selangor, Malaysia were elucidated. The overall mean user evaluation score of the mobile app was 4.0 out of 5 (SD=0.6), reflects its acceptability of the users. The PesTrapp, a one-stop solution, is anticipated to improve the entomological surveillance work processes. This new mobile app can contribute as a tool in the vector control countermeasure strategies.

Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso trial.

OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

After egg collection, can we predict the chance of embryos for day 5 transfer or freezing?

Even partway through an IVF cycle, at the point when a woman's eggs have been collected, it is hard to provide reliable answers to the common question of 'Am I likely to have a good embryo to transfer?' Sometimes, it only takes one good egg to be successful. However, doctors and patients are acutely aware that low egg numbers, older age and having conditions such as endometriosis can stack the odds against success. We have developed a model to try and answer this question for those patients who wish for more information to help guide their expectations after egg collection. A new tool is presented to predict whether a woman having IVF treatment will have a good enough embryo either to transfer on day 5 or freeze. It was built using information from all 2015 to 2016 UK cycles and predicts using age, number of eggs collected and cause of subfertility.

Streamlining follicular monitoring during controlled ovarian stimulation: a data-driven approach to efficient IVF care in the new era of social distancing.

STUDY QUESTION: What is the optimal follicular tracking strategy for controlled ovarian stimulation (COS) in order to minimise face-to-face interactions? SUMMARY ANSWER: As data from follicular tracking scans on Days 5, 6 or 7 of stimulation are the most useful to accurately predict trigger timing and risk of over-response, scans on these days should be prioritised if streamlined monitoring is necessary. WHAT IS KNOWN ALREADY: British Fertility Society guidance for centres restarting ART following coronavirus disease 2019 (COVID-19) pandemic-related shutdowns recommends reducing the number of patient visits for monitoring during COS. Current evidence on optimal monitoring during ovarian stimulation is sparse, and protocols vary significantly. Small studies of simplifying IVF therapy by minimising monitoring have reported no adverse effects on outcomes, including live birth rate. There are opportunities to learn from the adaptations necessary during these extraordinary times to improve the efficiency of IVF care in the longer term. STUDY DESIGN, SIZE, DURATION: A retrospective database analysis of 9294 ultrasound scans performed during monitoring of 2322 IVF cycles undertaken by 1875 women in a single centre was performed. The primary objective was to identify when in the IVF cycle the data obtained from ultrasound are most predictive of both oocyte maturation trigger timing and an over-response to stimulation. If a reduced frequency of clinic visits is needed due to COVID-19 precautions, prioritising attendance for monitoring scans on the most predictive cycle days may be prudent. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study comprised anonymised retrospective database analysis of IVF/ICSI cycles at a tertiary referral IVF centre. Machine learning models are used in combining demographic and follicular tracking data to predict cycle oocyte maturation trigger timing and over-response. The primary outcome was the day or days in cycle from which scan data yield optimal model prediction performance statistics. The model for predicting trigger day uses patient age, number of follicles at baseline scan and follicle count by size for the current scan. The model to predict over-response uses age and number of follicles of a given size. MAIN RESULTS AND THE ROLE OF CHANCE: The earliest cycle day for which our model has high accuracy to predict both trigger day and risk of over-response is stimulation Day 5. The Day 5 model to predict trigger date has a mean squared error 2.16 ± 0.12 and to predict over-response an area under the receiver operating characteristic curve 0.91 ± 0.01. LIMITATIONS, REASONS FOR CAUTION: This is a retrospective single-centre study and the results may not be generalisable to centres using different treatment protocols. The results are derived from modelling, and further clinical validation studies will verify the accuracy of the model. WIDER IMPLICATIONS OF THE FINDINGS: Follicular tracking starting at Day 5 of stimulation may help to streamline the amount of monitoring required in COS. Previous small studies have shown that minimal monitoring protocols did not adversely impact outcomes. If IVF can safely be made less onerous on the clinic's resources and patient's time, without compromising success, this could help to reduce burden-related treatment drop-out. STUDY FUNDING/COMPETING INTEREST(S): F.P.C. acknowledges funding from the NIHR Applied Research Collaboration Wessex. The authors declare they have no competing interests in relation to this work. TRIAL REGISTRATION NUMBER: N/A.

Delayed diagnosis and treatment of rheumatoid arthritis in Sarawak General Hospital.

INTRODUCTION: Rheumatoid arthritis (RA) is an autoimmune systemic inflammatory disorder characterised by symmetrical polyarthritis which leads to damage of joints if untreated. Early diagnosis and treatment of RA to achieve tight control of the disease will improve outcome and prevent disability. OBJECTIVE: We aimed to examine the delays in the diagnosis of RA in patients presenting to the Rheumatology Unit, Sarawak General Hospital (SGH). METHODS: Data on demographics and various delays were collected from the medical records from January 2015 until March 2018. Patient delay is defined as from the time onset of symptom to the first primary care presentation. Primary care delay is defined as from the first primary care presentation to referral to rheumatology. Rheumatology delay is defined as from rheumatology referral to appointment at the rheumatology clinic. Disease modifying anti-rheumatic drugs (DMARDS) delay is defined as from the rheumatology clinic appointment to starting DMARDS. Total delay is from symptom onset to starting DMARDS. RESULTS: There were 84 new patients diagnosed with rheumatoid arthritis, out of which 66 were females (78.6%). The mean age was 54.1±12.0 years. Only 19 patients (22.6%) were treated with DMARDS within 12 weeks of symptom onset. The median time for patient delay was four weeks (Interquartile range (IQR) 2-20 weeks), while the median time primary care delay was 11 weeks (IQR 4-24 weeks). The median time for rheumatology delay was zero weeks (IQR 0- 1 week) and the DMARDS delay was zero week (IQR 0). The median time from symptom onset to DMARDS initiation was 23.5 weeks (IQR 13.25-51 weeks). CONCLUSION: The delays in the diagnosis of rheumatoid arthritis were mainly from the patient and primary care.

Status of pyrethroid resistance in Aedes (Stegomyia) aegypti (Linneaus) from dengue hotspots in Klang Valley, Malaysia.

The continued absence of an effective and safe tetravalent dengue vaccine and the lack of specific anti-viral treatment have made mosquito vector control using chemical insecticides as the mainstream for dengue prevention and control. However, the long-term use of chemical insecticides may induce resistance. Hence detection of insecticide resistance in dengue vectors is crucially important in ensuring the insecticide-based intervention in dengue control program is still effective and reliable. In this study, the susceptibility status of Aedes aegypti from five selected dengue hotspots in Klang Valley, Malaysia against pyrethroids was determined by employing the World Health Organization (WHO) protocol of adult bioassay. Four types of pyrethroids were tested against adult female Aedes aegypti to determine the knockdown rate, post 24-h adult mortality and resistance ratio. All field-collected Aedes aegypti strains were resistant to the four pyrethroids tested, except for the Taman Sungai Jelok (TSJ) strain. Permethrin exhibited the lowest knockdown rate against Aedes aegypti, followed by deltamethrin, cyfluthrin and lambda-cyhalothrin. This present study indicated the widespread of pyrethroid resistance in Aedes aegypti in Klang Valley, indicating the needs of implementing alternative measures in vector control program. The data in this study can be utilised as an input for insecticide resistance management of Aedes aegypti in Malaysia.

Synergistic Antibacterial Effects of Metallic Nanoparticle Combinations.

Metallic nanoparticles have unique antimicrobial properties that make them suitable for use within medical and pharmaceutical devices to prevent the spread of infection in healthcare. The use of nanoparticles in healthcare is on the increase with silver being used in many devices. However, not all metallic nanoparticles can target and kill all disease-causing bacteria. To overcome this, a combination of several different metallic nanoparticles were used in this study to compare effects of multiple metallic nanoparticles when in combination than when used singly, as single elemental nanoparticles (SENPs), against two common hospital acquired pathogens (Staphylococcus aureus and Pseudomonas. aeruginosa). Flow cytometry LIVE/DEAD assay was used to determine rates of cell death within a bacterial population when exposed to the nanoparticles. Results were analysed using linear models to compare effectiveness of three different metallic nanoparticles, tungsten carbide (WC), silver (Ag) and copper (Cu), in combination and separately. Results show that when the nanoparticles are placed in combination (NPCs), antimicrobial effects significantly increase than when compared with SENPs (P < 0.01). This study demonstrates that certain metallic nanoparticles can be used in combination to improve the antimicrobial efficiency in destroying morphologically distinct pathogens within the healthcare and pharmaceutical industry.

Treat-to-target (T2T) of serum urate (SUA) in gout: a clinical audit in real-world gout patients.

Treat-to-target (T2T) for gout has been established recently to improve its management, which has been reported to be sub-optimal with significant gaps between the goals of treatment and day-to-day clinical practice. T2T recommended a goal of serum urate (SUA) target of <360 µmoI/L in all patients with gout and <300 µmoI/L in patients with tophaceous or severe gout. T2T strategy was applied in the management of gout patients in two Rheumatology clinics from 1 January 2016 onwards. We performed a clinical audit to assess T2T of SUA in gout patients and to identify causes for failure to achieve target SUA among them. There were a total of 304 patients for our analysis. They were of multi-ethnic origin with male predominance (88.8%). They had a mean age of 57.7+13.7 years and mean disease duration of 10.1+8.7 years. The most common comorbidities were hypertension (76.2%), dyslipidemia (52.5%) and diabetes mellitus (DM) (27.4%). Our patients' body mass indexes showed that 47.7% were obese while 34.2% were overweight. Up to 62.4% of our patients had tophi and 42.6% had joint deformities. Only 34.9% of patients achieved target SUA. Nonadherence (52.3%) was the main reason identified for failure to achieve target SUA. The independent predictors for failure to achieve target SUA were nonadherence (HR=7.84, p=0.000) and presence of tophi (HR=1.95, p=0.001).

A rare cause of back pain and radiculopathy - spinal tophi: a case report.

BACKGROUND: Gout is a monosodium urate deposition disease which is prevalent worldwide. The usual manifestations are crystal arthropathy and tophi deposition in the soft tissues. Spinal tophi may also occur and are rarely reported, resulting in various clinical manifestations such as back pain, spinal cord compression, radiculopathy, and even mimicking epidural abscess and spondylodiscitis. CASE PRESENTATION: We report a case of a 42-year-old Chinese man with underlying gout who presented with back pain and radiculopathy. The diagnosis of spinal tophi was unsuspected and he was initially treated for epidural abscess and spondylodiscitis. He underwent a laminectomy and posterolateral fusion during which tophus material was discovered. He recovered and medications for gout were started. CONCLUSION: Spinal tophi are rare. The diagnosis is difficult and spinal tophi may be mistaken for epidural abscess, spondylodiscitis, or neoplasm.

Chronic granulomatous mastitis with axillary lymphadenopathy in a nulliparous woman.

Chronic Granulomatous Mastitis (CGM) is a rare disorder and this generally occurs in young women with a recent history of lactation. Development of this disease in nulliparous women are rare with an incidence of 10%. Axillary lymphadenopathy is seen in 15% of cases diagnosed with CGM. We present a case of CGM in a 23- year-old nulliparous woman presenting with a breast mass and multiple axillary lymphadenopathy. To the best of our knowledge there are no documented cases of both these rare clinical features occurring simultaneously. The use of oral steroids prevented surgery and effectively induced remission.

Breast cancer with dermatomyositis as initial presentation.

Patients with breast cancer normally present with breast lump or abnormal mammogram. Dermatomyositis is rarely the first presentation. We present a case of a 63-year-old woman who had generalised dermatitis, progressive fatigue and muscle weakness. She was first diagnosed as dermatomyositis and subsequently breast cancer. Her rash and muscle weakness progressed drastically over a month. Tumescent mastectomy and axillary surgery was performed, which led to gradual regression of her dermatomyositis over six months. This case report emphasized in the benefit of early diagnosis and treatment of dermatomyositis and breast cancer. Pros and cons of tumescent mastectomy is discussed as well.

Gyrospun antimicrobial nanoparticle loaded fibrous polymeric filters.

A one step approach to prepare hybrid nanoparticle embedded polymer fibres using pressurised gyration is presented. Two types of novel antimicrobial nanoparticles and poly(methylmethacrylate) polymer were used in this work. X-ray diffraction analysis of the nanoparticles revealed Ag, Cu and W are the main elements present in them. The concentration of the polymer solution and the nanoparticle concentration had a significant influence on the fibre diameter, pore size and morphology. Fibres with a diameter in the range of 6-20µm were spun using 20wt% polymer solutions containing 0.1, 0.25 and 0.5 wt% nanoparticles under 0.3MPa working pressure and a rotational speed of 36,000rpm. Continuous, bead-free fibre morphologies were obtained for each case. The pore size in the fibres varied between 36 and 300nm. Successful incorporation of the nanoparticles in polymer fibres was confirmed by energy dispersive x-ray analysis. The fibres were also gyrospun on to metallic discs to prepare filters which were tested for their antibacterial activity on a suspension of Pseudomonas aeruginosa. Nanoparticle loaded fibres showed higher antibacterial efficacy than pure poly(methylmethacrylate) fibres.

Systemic lupus erythematosus pregnancies: ten-year data from a single centre in Malaysia.

We performed a retrospective study of all systemic lupus erythematosus (SLE) pregnancies during a 10-year period (2006-2015) to describe the clinical features, maternal and foetal outcomes in our centre. There were 115 pregnancies in 86 women with SLE. Our patients had a mean age of 29.1 years (SD 5.80) and a mean disease duration of 44.63 months (SD 41.17). Fifteen patients had antiphospholipid syndrome (APS). Our patients had complicated pregnancies: 26.1% had SLE flares, 13.9% had pre-eclampsia and 45.1% needed caesarean sections. There were 23.3% foetal losses and 25% preterm deliveries in our patients. There was a higher rate of unplanned pregnancies and lupus flare among pregnancies with active SLE at conception. Pregnancies in lupus nephritis have higher incidence of lupus flares during pregnancy but similar maternal and foetal outcomes compared to those without nephritis. The prognostic indicators for adverse foetal outcome in our patients were flare of SLE (HR 4.08 [CI 95% 1.65-10.13, p < 0.01]) and APS (HR 3.07 [CI 95% 1.12-8.42, p < 0.05]) and the prognostic indicator for adverse maternal outcome was hypertension (HR 3.58 [CI 95% 1.30-9.90, p < 0.05]). Lupus pregnancies in our centre remained as high-risk pregnancies with significant maternal and foetal complications.

Nonlinear control of high-frequency phonons in spider silk.

Spider dragline silk possesses superior mechanical properties compared with synthetic polymers with similar chemical structure due to its hierarchical structure comprised of partially crystalline oriented nanofibrils. To date, silk's dynamic mechanical properties have been largely unexplored. Here we report an indirect hypersonic phononic bandgap and an anomalous dispersion of the acoustic-like branch from inelastic (Brillouin) light scattering experiments under varying applied elastic strains. We show the mechanical nonlinearity of the silk structure generates a unique region of negative group velocity, that together with the global (mechanical) anisotropy provides novel symmetry conditions for gap formation. The phononic bandgap and dispersion show strong nonlinear strain-dependent behaviour. Exploiting material nonlinearity along with tailored structural anisotropy could be a new design paradigm to access new types of dynamic behaviour.

Adhesions and endometriosis: challenges in subfertility management : (An expert opinion of the ANGEL-The ANti-Adhesions in Gynaecology Expert PaneL-group).

There is molecular evidence that endometriosis has a negative impact on the ovaries, although the exact pathophysiology concerning endometriosis-associated subfertility is not known. The negative impact on the tubo-ovarian unit can be directly by distorting the anatomy, indirectly by invoking inflammation or by oxidative damage with poorer-quality oocytes. Endometriosis even seems to have a negative effect on pregnancy outcome after in vitro fertilization.

Piceatannol, a natural hydroxylated analog of resveratrol, promotes nitric oxide release through phosphorylation of endothelial nitric oxide synthase in human endothelial cells.

OBJECTIVE: Endothelial dysfunction associated with many cardiovascular diseases is largely due to reduced nitric oxide (NO) derived from endothelial NO synthase (eNOS). Piceatannol (trans-3,4,3',5'-tetrahydroxystilbene; Pic) is reported to have cardiovascular therapeutic effects. However, the cellular and molecular mechanisms underlying the cardioprotective effects of Pic are still unclear. Here, we investigated whether Pic could influence endothelial NO release in human umbilical vein endothelial cells (HUVECs). MATERIALS AND METHODS: In HUVECs exposed to Pic, NO production and phosphorylation of eNOS and protein kinase B (Akt) were determined by using a commercially available NO assay kit and Western blot analysis, respectively. RESULTS: Pic stimulated dose- and time-dependent NO production via eNOS phosphorylation. Pic also stimulated dose-dependent phosphorylation of Akt. Interestingly, NO production and eNOS phosphorylation in response to Pic were significantly abolished by the phosphoinositide 3-kinase (PI3K)/Akt inhibitor LY294002. CONCLUSIONS: Pic is capable of inducing eNOS phosphorylation and the subsequent NO release, presumably, by activating PI3K/Akt pathway. The potential efficacy of Pic, a natural hydroxylated analog and a metabolite of resveratrol, may aid in the prevention of cardiovascular diseases characterized by endothelial dysfunction.