Predicting antibiotic susceptibility in urinary tract infection with artificial intelligence-model performance in a multi-centre cohort.

Objective: To develop an artificial intelligence model to predict an antimicrobial susceptibility pattern in patients with urinary tract infection (UTI). Materials and methods: 26 087 adult patients with culture-proven UTI during 2015-2020 from a university teaching hospital and three community hospitals in Hong Kong were included. Cases with asymptomatic bacteriuria (absence of diagnosis code of UTI, or absence of leucocytes in urine microscopy) were excluded. Patients from 2015 to 2019 were included in the training set, while patients from the year 2020 were included as the test set.Three first-line antibiotics were chosen for prediction of susceptibility in the bacterial isolates causing UTI: namely nitrofurantoin, ciprofloxacin and amoxicillin-clavulanate. Baseline epidemiological factors, previous antimicrobial consumption, medical history and previous culture results were included as features. Logistic regression and random forest were applied to the dataset. Models were evaluated by F1-score and area under the curve-receiver operating characteristic (AUC-ROC). Results: Random forest was the best algorithm in predicting susceptibility of the three antibiotics (nitrofurantoin, amoxicillin-clavulanate and ciprofloxacin). The AUC-ROC values were 0.941, 0.939 and 0.937, respectively. The F1 scores were 0.938, 0.928 and 0.906 respectively. Conclusions: Random forest model may aid judicious empirical antibiotics use in UTI. Given the reasonable performance and accuracy, these accurate models may aid clinicians in choosing between different first-line antibiotics for UTI.

Cranial sagittal vertical axis to the hip as the best sagittal alignment predictor of patient-reported outcomes at 2 years postoperatively in adult spinal deformity surgery.

OBJECTIVE: The objective was to discern whether the cranial sagittal vertical axis (CrSVA) can best predict the trajectory of patient-reported outcome measures (PROMs) at 2 years postoperatively. METHODS: This was a retrospective cohort study of prospectively collected adult spinal deformity patient data. CrSVA relative to the sacrum, hip (CrSVA-H), knee, and ankle was measured as the horizontal distance to the vertical plumb line from the nasion-inion midpoint, with positive values indicating an anterior cranium. Standard sagittal alignment parameters were also collected. Outcome variables were PROMs as measured by Scoliosis Research Society-22r questionnaire (SRS-22r) total and subdomain scores and the Oswestry Disability Index. Pearson's correlation coefficients and univariate regressions were performed to investigate associations between predictors and PROMs. Two conceptual multivariable linear regression models for each 2-year outcome measure were built after adjusting for the impact of preoperative SRS-22r scores. Model 1 assessed pre- and postoperative alignment only relative to C2 and C7, while model 2 assessed alignment relative to C2 and C7 as well as the cranium. RESULTS: There was a total of 363 patients with 2 years of radiographic and PROM follow-up (68.0% female, mean [standard error of the mean] age 60.8 [0.78] years, BMI 27.5 [0.29], and total number of instrumented levels 12.8 [0.22]). CrSVA measures were significantly associated with the 2-year SRS-22r total and subdomain scores. In univariate regression, revision surgery, number of prior surgeries, frailty, BMI, total number of osteotomies, and lower baseline total SRS-22r score as well as postoperative sagittal alignment were significantly associated with worse 2-year SRS-22r scores. In multivariable regression, after adjusting for baseline SRS-22r scores, greater preoperative C2 to sacrum sagittal vertical axis (SVA) and C7 SVA were found to be the only independent predictors of 2-year total SRS-22r score (ß = -0.011 [p = 0.0026] and ß = 0.009 [p = 0.0211], respectively) when alignment was considered only relative to C2. However, in the subsequent model, CrSVA-H replaced C7 SVA as the independent factor driving postoperative SRS-22r total scores (ß = -0.006, p < 0.0001). That is, when the model included alignment relative to the cranium, C2, and C7, greater or more anterior CrSVA-H resulted in worse SRS-22r scores, while smaller or more posterior CrSVA-H resulted in better scores. Similar models for subdomains again found CrSVA-H to be the best predictor of function (ß = -0.0095, p < 0.0001), pain (ß = -0.0091, p < 0.0001), self-image (ß = -0.0084, p = 0.0004), and mental health (ß = -0.0059, p = 0.0026). CONCLUSIONS: In multivariable regression, C7 SVA was supplanted by CrSVA-H alignment as a significant, independent predictor of 2-year SRS-22r scores in patients with adult spinal deformity and should be considered as one of the standard postoperative sagittal alignment target goals.

Synergism of colistin and globular endolysins against multidrug-resistant gram-negative bacteria.

Endolysins (lysins), a novel class of antibacterial agents derived from bacteriophages, efficiently lyse bacteria by degrading the peptidoglycan layer within the bacterial wall. Colistin, a classic peptide antibiotic with the ability to permeabilize the outer membrane, has recently shown great promise in synergizing with lysins against gram-negative bacteria. However, the exact mechanisms responsible for their synergy remain unclear. Here, we first demonstrated the synergistic bacterial killing of various lysin and colistin combinations. With a model lysin, LysAB2, we then confirmed that there is a threshold concentration of colistin causing sufficient permeabilization of the outer membrane for lysin to access the peptidoglycan layer and subsequently exert its lytic ability. The threshold colistin concentrations were found to range 0.2-0.8 µM for the tested bacteria, with the exact value largely depending on the density of lipopolysaccharides on the outer membrane. Beyond the threshold colistin level, LysAB2 could synergize with colistin at a concentration as low as 0.31 µM. Next, we proved for the first time that lysin-induced degradation of the peptidoglycan layer facilitated the disruption of cytoplasmic membrane by colistin, elevated the level of reactive oxygen species in bacterial cells, and boosted the killing effect of colistin. Additionally, the colistin-lysin combination could effectively eliminate established biofilms due to the biofilm dispersal ability of lysin. The in-vivo efficacy was preliminary confirmed in a Galleria mellonella infection model for combination with colistin doses (≥ 1.8 µg/larvae), which could reach beyond the threshold concentration, and a fixed LysAB2 dose (10 µg/larvae). In summary, our study provided the first experimental evidence unravelling the mechanisms behind the synergy of colistin and lysins. All these findings provided important insights in guiding the dosing strategy for applying this combination in future development.

Health literacy in medical imaging: a scoping review of current evidence and future directions.

OBJECTIVE: The importance of health literacy in medical imaging is well recognized, yet the current landscape remains inadequately understood. This study aims to explore the extent of health literacy studies contextualized to medical imaging. STUDY DESIGN: Scoping review. METHODS: A scoping review was conducted using three online bibliographic databases namely, PubMed, ScienceDirect, and CINAHL. We have adopted the concept of health literacy, as a clinical risk and personal asset, to guide this review. RESULTS: Of 311 unique articles, 39 met our selection criteria. Five themes (categories) were identified by the authors: appropriate communication with patients who receive medical imaging test results, appropriate usage of medical imaging, classes and characteristics of eHealth literacy, disease/deterioration prevention, and patient education. Additionally, 17 health literacy assessment tools were identified, including 11 original creations. Finally, 11 recommendations have emerged from this scoping review, offering valuable insights into methods, considerations, and strategies for promoting health literacy. CONCLUSIONS: Health literacy studies in medical imaging cover both clinical and public health perspectives, benefiting diverse populations, regardless of underlying medical conditions. Notably, the majority of assessment tools used in these studies were author-generated, hindering cross-study comparisons. Given the innate capacity of medical images to convey intuitive information, those images do not solely benefit the patients who are given medical imaging examinations, but they also hold significant potential to enhance public health literacy. Health literacy and medical imaging are closely associated and mutually reinforce each other.

Early Metabolomic and Immunologic Biomarkers as Prognostic Indicators for COVID-19.

This prospective study in Hong Kong aimed at identifying prognostic metabolomic and immunologic biomarkers for Coronavirus Disease 2019 (COVID-19). We examined 327 patients, mean age 55 (19-89) years, in whom 33.6% were infected with Omicron and 66.4% were infected with earlier variants. The effect size of disease severity on metabolome outweighed others including age, gender, peak C-reactive protein (CRP), vitamin D and peak viral levels. Sixty-five metabolites demonstrated strong associations and the majority (54, 83.1%) were downregulated in severe disease (z score: -3.30 to -8.61). Ten cytokines/chemokines demonstrated strong associations (p < 0.001), and all were upregulated in severe disease. Multiple pairs of metabolomic/immunologic biomarkers showed significant correlations. Fourteen metabolites had the area under the receiver operating characteristic curve (AUC) > 0.8, suggesting a high predictive value. Three metabolites carried high sensitivity for severe disease: triglycerides in medium high-density lipoprotein (MHDL) (sensitivity: 0.94), free cholesterol-to-total lipids ratio in very small very-low-density lipoprotein (VLDL) (0.93), cholesteryl esters-to-total lipids ratio in chylomicrons and extremely large VLDL (0.92);whereas metabolites with the highest specificity were creatinine (specificity: 0.94), phospholipids in large VLDL (0.94) and triglycerides-to-total lipids ratio in large VLDL (0.93). Five cytokines/chemokines, namely, interleukin (IL)-6, IL-18, IL-10, macrophage inflammatory protein (MIP)-1b and tumour necrosis factor (TNF)-a, had AUC > 0.8. In conclusion, we demonstrated a tight interaction and prognostic potential of metabolomic and immunologic biomarkers enabling an outcome-based patient stratification.

Feasibility of low contrast volume and low injection flow rate in CT pulmonary angiography.

BACKGROUND: Computed Tomography Pulmonary Angiography (CTPA) is currently the gold standard for diagnosing Pulmonary Embolism (PE), with a high flowrate (>4.5ml/s) for contrast media (CM) administration recommended for sufficient pulmonary artery opacification. However, this may not be achievable for patients with challenging IV access. AIM: To determine if a low volume CM, low flowrate (LVLF) CTPA protocol produces images of similar image quality compared to a standard protocol in two aspects, in terms of peak arterial enhancement through the quantitative measurement of Hounsfield unit (HU) and based on subjective overall image quality. METHODS: Retrospective collection of 151 patients who underwent CTPA via 320 slice multi-detector CT due to clinical suspicion of PE. 80 patients underwent the standard protocol, with a fixed flowrate of 4.5ml/s and 50ml of CM, while 71 patients underwent the LVLF protocol with up to a 37% and 30% reduction in flowrate and CM administered, respectively. Two independent radiographers measured the attenuation of multiple pulmonary arteries in HU, with ≥200HU being considered diagnostic. Overall image quality was also reviewed using a 5-point close-ended questionnaire by two independent radiologists. RESULTS: There was no significant difference in terms of attenuation measured in HU for the seven regions of interest (main pulmonary trunk, right and left pulmonary arteries, right and left lobar arteries, and right and left subsegmental arteries (RSA and LSA)) between the LVLF and standard CTPA protocol. Similarly, there were no significant differences in the overall image quality score obtained from standard and LVLF protocols reported by both radiologists. CONCLUSION: The LVLF protocol can achieve similar enhancement and subjective image quality as the standard CTPA protocol, potentially allowing for further optimisation in the CM dosage.

The Effect of PEEP on Pulmonary Vascular Resistance Depends on Lung Recruitability in ARDS Patients.

Rationale. A U-shape relationship should exist between lung volume and pulmonary vascular resistance (PVR), with minimal PVR at functional residual capacity. Thus, positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS) should increase PVR if it induces significant lung distension compared to recruitment. However, this has never been proven in patients. Objectives. To study the effects of PEEP on PVR according to lung recruitability, evaluated by the recruitment-to-inflation (R/I) ratio. Methods. In patients with ARDS, we measured hemodynamic (pulmonary artery catheter), echocardiographic and ventilatory variables (including esophageal pressure), at both low PEEP and higher PEEP by 10 cmH2O. Preload responsiveness was assessed by the passive leg raising test at high PEEP. Measurements and Main Results. We enrolled 23 patients, including 10 low recruiters (R/I <0.5) and 13 high recruiters (R/I ≥0.5). Raising PEEP from 4 (2-5) to 14 (12-15) cmH2O increased PVR in low recruiters (from 160 (120-297) to 243 (166-380) dyn.s/cm5, p<0.01), while PVR was unchanged in high recruiters (from 224 (185-289) to 235 (168-300) dyn.s/cm5, p=0.55). Right-to-left ventricular end-diastolic areas ratio simultaneously increased in low recruiters (from 0.54 (0.50-0.59) to 0.64 (0.56-0.70), p<0.01), while remaining stable in high recruiters (from 0.70 (0.65-0.79) to 0.68 (0.58-0.80), p=0.48). Raising PEEP decreased cardiac index only in preload responsive patients. Conclusions. PEEP increases PVR only when it induces significant lung distension compared to recruitment according to the recruitment-to-inflation ratio. Tailoring PEEP on this recruitability index should mitigate its hemodynamic effects.

Chronic post-COVID neuropsychiatric symptoms persisting beyond one year from infection: a case-control study and network analysis.

Our study aims to delineate the phenotypes of chronic neuropsychiatric symptoms among adult subjects recovering from their first COVID that occurred more than one year ago. We also aim to explore the clinical and socioeconomic risk factors of having a high loading of chronic neuropsychiatric symptoms. We recruited a post-COVID group who suffered from their first pre-Omicron COVID more than a year ago, and a control group who had never had COVID. The subjects completed app-based questionnaires on demographic, socioeconomic and health status, a COVID symptoms checklist, mental and sleep health measures, and neurocognitive tests. The post-COVID group has a statistically significantly higher level of fatigue compared to the control group (p < 0.001). Among the post-COVID group, the lack of any COVID vaccination before the first COVID and a higher level of material deprivation before the COVID pandemic predicts a higher load of chronic post-COVID neuropsychiatric symptoms. Partial correlation network analysis suggests that the chronic post-COVID neuropsychiatric symptoms can be clustered into two major (cognitive complaints -fatigue and anxiety-depression) and one minor (headache-dizziness) cluster. A higher level of material deprivation predicts a higher number of symptoms in both major clusters, but the lack of any COVID vaccination before the first COVID only predicts a higher number of symptoms in the cognitive complaints-fatigue cluster. Our result suggests heterogeneity among chronic post-COVID neuropsychiatric symptoms, which are associated with the complex interplay of biological and socioeconomic factors.

Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine.

PURPOSE: To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU). METHODS: The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively). RESULTS: We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting. CONCLUSION: This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.

Left ventricular global longitudinal strain and acute myocardial injury in patients with sickle cell disease admitted to the intensive care unit for vaso-occlusive crisis.

In patients with sickle cell disease (SCD), SCD-related cardiomyopathy may be partly due to repeated ischaemic events related to sickling during vaso-occlusive crises, but few clinical studies support this hypothesis. We evaluated the incidence of acute myocardial ischaemia during vaso-occlusive crises as assessed by the left ventricular global longitudinal strain (LVGLS) and high-sensitive cardiac troponin T (hs-cTnT). We included adult patients with SCD admitted to the intensive care unit (ICU) for vaso-occlusive crisis. We collected hs-cTnT and measured LVGLS with echocardiography at admission (day 1), day 2, day 3 and ICU discharge. Among 55 patients included, considering only the first hospitalization of patients admitted several times, 3 (5%) had elevated hs-cTnT at ≥1 time point of the ICU stay. It was ≤2 times the upper limit of normal in two of these patients. LVGLS was altered at ≥1 time point of the ICU stay in 13 (24%) patients. Both hs-cTnT and LVGLS were abnormal at ≥1 time point of the hospital stay in 2 (4%) patients. Acute myocardial injury as assessed by troponin elevation and LVGLS impairment was a rare event during vaso-occlusive crises.

A machine learning-based risk score for prediction of infective endocarditis among patients with Staphylococcus aureus bacteraemia - The SABIER score.

BACKGROUND: Early risk assessment is needed to stratify Staphylococcus aureus infective endocarditis (SA-IE) risk among Staphylococcus aureus bacteraemia (SAB) patients to guide clinical management. The objective of this study is to develop a novel risk score independent of subjective clinical judgment and can be used early at the time of blood culture positivity. METHODS: We conducted a retrospective big data analysis from territory-wide electronic data and included hospitalized patients with SAB between 2009 and 2019. We applied a random forest risk scoring model to select variables from an array of parameters, according to the statistical importance of each feature in predicting SA-IE outcome. The data was divided into derivation and validation cohorts. The areas under the curve of the receiver operating characteristic (AUCROC) were determined. RESULTS: We identified 15,741 SAB patients, among them 4.18% had SA-IE. The AUCROC was 0.74 (95%CI 0.70-0.76), with a negative predictive value of 0.980 (95%CI 0.977-0.983). The four most discriminatory features were age, history of infective endocarditis, valvular heart disease, and being community-onset. CONCLUSION: We developed a novel risk score with good performance as compared to existing scores and can be used at the time of SAB and prior to subjective clinical judgment.

Prevalence of oral human papillomavirus infection among the general adult population in Hong Kong.

A cross-sectional study in 2021-23 collected oral rinse gargle samples from an human papillomaviruses (HPV) vaccine-naïve general adult population in Hong Kong. HPV was detected by a PCR using SPF10 primers, and genotyped by a linear array covering 25 genotypes. Epidemiologic information including sociodemographics, medical history, oral health, and sexual behavior were collected by a self-administered questionnaire. Altogether, 2323 subjects aged 18-75 (median 47) years with 50.1% male were recruited. The prevalence for oral HPV infection with all genotypes combined, high-risk, and low-risk genotypes was 1.5%, 0.7%, and 0.7%, respectively; and with no statistically significant difference between participant gender. The prevalence increased with age and was highest in women at 45-54 years (2.7% for all genotypes combined), and highest in men aged >64 years (4.1% for all genotypes combined). HPV52 was the most common genotype among all participants. Univariate analysis suggested more lifetime sexual or oral sexual partners as risk factors, but they did not reach statistical significance upon multivariate analysis; whereas higher educational level had an independent protective effect. To conclude, oral HPV prevalence increased with age in Hong Kong. Strategies to prevent oral HPV infection and the associated cancers are urgently needed.

Knee flexion compensation in postoperative adult spinal deformity patients: implications for sagittal balance and clinical outcomes.

PURPOSE: To determine whether maintaining good sagittal balance with significant knee flexion (KF) constitutes a suboptimal outcome after adult spinal deformity (ASD) correction. METHODS: This single-center, single-surgeon retrospective study, assessed ASD patients who underwent posterior spinal fusion between 2014 and 2020. Inclusion criteria included meeting at least one of the following: PI-LL ≥ 25°, T1PA ≥ 20°, or CrSVA-H ≥ 2 cm. Those with lower-extremity contractures were excluded. Patients were classified into four groups based on their 6-week postoperative cranio-hip balance and KF angle, and followed for at least 2 years: Malaligned with Knee Flexion (MKF+) (CrSVA-H > 20 mm + KFA > 10), Malaligned without Knee Flexion (MKF-) (CrSVA-H > 20 mm + KFA < 10), Aligned without Knee Flexion (AKF-) (CrSVA-H < 20 mm + KFA < 10), and Aligned with Knee Flexion (AKF+) (CrSVA-H < 20 mm + KFA > 10). The primary outcomes of this study included one and two year reoperation rates. Secondy outcomes included clinical and patient reported outcomes. RESULTS: 263 patients (mean age 60.0 ± 0.9 years, 74.5% female, and mean Edmonton Frailty Score 3.3 ± 0.2) were included. 60.8% (160/263 patients) exhibited good sagittal alignment at 6-week postop without KF. Significant differences were observed in 1-year (p = 0.0482) and 2-year reoperation rates (p = 0.0374) across sub-cohorts, with the lowest and highest rates in the AKF- cohort (5%, n = 8) and MKF + cohort (16.7%, n = 4), respectively. Multivariable Cox regression demonstrated the AKF- cohort exhibited significantly better reoperation outcomes compared to other groups: AKF + (HR: 5.24, p = 0.025), MKF + (HR: 31.7, p < 0.0001), and MKF- (HR: 11.8, p < 0.0001). CONCLUSION: Our findings demonstrate that patients relying on knee flexion compensation in the early postoperative period have inferior outcomes compared to those achieving sagittal balance without knee flexion. When compared to malaligned patients, those with CrSVA-H < 20 mm and KFA > 10 degrees experience fewer early reoperations but similar delayed reoperation rates. This insight emphasizes the importance of considering knee compensation perioperatively when managing sagittal imbalance in clinical practice.

Changes in the Incidence and Human Papillomavirus-Positive Portion of Oropharyngeal Squamous Cell Carcinoma in Hong Kong.

The incidence of human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) is rising in the West, but little is known in Asia. This study elucidated changes in the incidence and HPV-positive portion of OPSCC in Hong Kong. Data from population-based cancer registry were used to analyze the incidence of OPSCC in association with other head and neck cancers. Archived tumor tissues were tested for HPV. From 1986 to 2020, there was a marked decrease in the incidence of nasopharyngeal and laryngeal cancers, but a persistent increase in OPSCC from 36 cases in 1986 to 116 cases in 2020. The average positive rate for high-risk HPV was 36.1% (112/310) among OPSCC diagnosed in 2010-2020. The HPV-positive rate in recent years was significantly higher than earlier cases (tonsil SCC: 64.7% (55/85) in 2016-2020 vs. 40.4% (19/47) in 2010-2015, p = 0.007). Patients with HPV-positive tonsil cancers were significantly younger than those negative (mean [SD]: 58.9 [9.9] vs. 64.3 [13.3] years, p = 0.006), but no significant difference was observed between genders. A persistent increase in the incidence of oropharyngeal cancer over the last few decades was observed in Hong Kong, which can be explained by the remarkable increase in HPV-positive tonsil cancers.

Do adult spinal deformity patients who achieve and maintain PI-LL < 10 have better patient-reported and clinical outcomes compared to patients with PI-LL ≥ 10? A propensity score-matched analysis.

PURPOSE: To investigate whether patients with spinopelvic mismatch (PI-LL ≥ 10) report worse patient-reported outcomes (PROs) compared to patients who achieve PI-LL < 10 at 2-year postop. METHODS: In this retrospective study, propensity score matching (PSM) was used to analyze patients who underwent posterior spinal fusion due to deformity, as defined by one or more of the following criteria: PI-LL ≥ 25°, T1 pelvic angle ≥ 30°, sagittal vertical axis ≥ 15 cm, thoracic scoliosis ≥ 70°, thoracolumbar scoliosis ≥ 50°, coronal malalignment ≥ 7 cm, or those who underwent a three-column osteotomy or fusion with ≥ 12 levels. Key outcomes were total Scoliosis Research Society-22r, Oswestry Disability Index (PROs), and reoperation at 1- and 2-year postop. Patients were dichotomized based on their 2-year alignment: PI-LL ≥ 10° and PI-LL < 10°. A multivariable logistic regression model identified factors associated with achieving PI-LL < 10°, and independent predictors were matched using propensity score matching. Binary outcomes within matched cohorts were analyzed using the McNemar test, while continuous outcomes were analyzed using the Wilcoxon rank-sum test. RESULTS: One hundred sixty-four patients with 2-year follow-up were included; mean age was 50.5 (standard error mean (SEM): 1.4) years, body mass index was 24.1(SEM 1.0), and number of operative levels was 13.5 (SEM 0.3). 84 (51.2%) and 80 (48.8%) patients achieved PI-LL < 10 and PI-LL ≥ 10 at 2-year follow-up, respectively. Baseline pelvic incidence [odds ratio (OR): 0.96 (95% CI 0.92-0.99)] and baseline PI-LL [OR: 0.95 (95% CI 0.9-0.99)] were independent predictors of achieving PI-LL < 10 at 2 years. When comparing propensity matched pairs, no significant differences were found in baseline PROs. At both 1- and 2-year follow-up, outcomes on the SRS-22r scale were nearly identical for both groups (function [4.1(0.1) vs 4.0 (0.1), P = 0.75] ,Pain [3.9 (0.2) vs 3.9 (0.2), P = 0.86], appearance [4.2 (0.2) vs 3.8 (0.2), P = 0.08], mental health [4.1 (0.2) vs 4.1 (0.1), P = 0.96], satisfaction [4.4 (0.2) vs 4.4 (0.2), P = 0.72], and total [90.2 (2.5) vs 88.1 (2.5), P = 0.57]). Additionally, ODI scores at 2 years were comparable [18.1 (2.9) vs 22.4 (2.9), P = 0.30]. The 90-day reoperation rate was 2.6% (one patient) in both matched cohorts (P > 0.99). There was no significant difference in 1-year (P > 0.9999) or 2-year (P = 0.2207) reoperation rates between the groups. CONCLUSION: Patients who achieve and maintain PI-LL < 10 2-years postop following adult spinal deformity surgery have nearly identical SRS-22r and ODI outcomes, and comparable 2-year reoperation rates as compared to patients who have PI-LL ≥ 10.

Problematic Smartphone Usage in Singaporean University Students: An Analysis of Self-Reported Versus Objectively Measured Smartphone Usage Patterns.

INTRODUCTION: Problematic smartphone usage is the excessive usage of the smartphone, leading to addiction symptoms that impair one's functional status. Self-administered surveys developed to describe the symptoms and measure the risk of problematic smartphone usage have been associated with depressive symptoms, symptoms of anxiety disorder, and perceived stress. However, self-reported smartphone usage can be unreliable, and previous studies have identified a better association between objectively measured smartphone usage and problematic smartphone usage. METHODOLOGY: A self-administered survey was used to investigate the relationships between the risk of problematic smartphone usage (SAS-SV) with depressive symptoms (PHQ-9), anxiety disorder symptoms (GAD-7), and perceived stress (PSS) in Singaporean full-time university students. Self-reported screentime and objectively measured screentime were collected to determine if there is any difference between perceived smartphone usage and objective smartphone usage. RESULTS: There was no statistical difference between self-reported and app-measured screentime in the study population. However, there were significant positive correlations between SAS-SV with PHQ-9, GAD-7, and PSS. In the logistic regression model, PHQ-9 was found to be the sole predictor for variances in SAS-SV score in the study population. CONCLUSION: This study suggests that problematic smartphone usage may potentially related to depressive symptoms, symptoms of anxiety disorder, and greater perceived stress in university students.

Effect on capillary refill time of volume expansion and increase of the norepinephrine dose in patients with septic shock.

BACKGROUND: Capillary refill time (CRT) has been suggested as a variable to follow during the course of septic shock. We systematically investigated the effects on CRT of volume expansion and norepinephrine. METHODS: In 69 septic shock patients, we recorded mean arterial pressure (MAP), cardiac index (CI), and 5 consecutive CRT measurements (video method, standardized pressure applied on the fingertip) before and after a 500-mL saline infusion in 33 patients and before and after an increase of the norepinephrine dose in 36 different patients. Fluid responders were defined by an increase in CI ≥ 15%, and norepinephrine responders by an increase in MAP ≥ 15%. RESULTS: The least significant change of CRT was 23%, so that changes in CRT were considered significant if larger than 23%. With volume expansion, CRT remained unchanged on average in patients with baseline CRT < 3 s (n = 7) and in all but one patient with baseline CRT ≥ 3 s in whom fluid increased CI < 15% (n = 13 "fluid non-responders"). In fluid responders with baseline CRT ≥ 3 s (n = 13), CRT decreased in 8 patients and remained unchanged in the others, exhibiting a dissociation between CI and CRT responses. The proportion of patients included > 24 h after starting norepinephrine was higher in patients with such a dissociation than in the other ones (60% vs. 0%, respectively). Norepinephrine did not change CRT significantly (except in one patient) if baseline CRT was ≥ 3 s and the increase in MAP < 15% (n = 6). In norepinephrine responders with prolonged baseline CRT (n = 11), it increased in 4 patients and remained unchanged in the other ones, which exhibited a dissociation between MAP and CRT responses. CONCLUSIONS: In septic shock patients with prolonged CRT, CRT very rarely improves with treatment when volume expansion increases cardiac output < 15% and increasing norepinephrine increases MAP < 15%. When the effects of fluid infusion on cardiac output and of norepinephrine on MAP are significant, the response of CRT is variable, as it decreases in some patients and remains stable in others which exhibit a dissociation between changes in macrohemodynamic variables and in CRT. In this regard, CRT behaves as a marker of microcirculation. TRIAL REGISTRATION: ClinicalTrial.gov (NCT04870892). Registered January15, 2021. Ethics committee approval CE SRLF 21-25.

The association between tibial torsion, knee flexion excursion and foot progression during gait in people with knee osteoarthritis: a cross-sectional study.

BACKGROUND: Lower limb malalignment is associated with gait kinematics, but there is limited information on the relationship between gait kinematics and tibial torsion in individuals with knee osteoarthritis (OA). This study aimed to investigate possible associations between tibial torsion and early stance kinematics during gait in people with mild and moderate medial knee OA. METHODS: Forty-seven participants (age: 62.1 ± 6.0 years; female/male: 37/10) diagnosed with medial knee OA were recruited from a regional hospital. Thirty of them had mild and seventeen had moderate knee OA. Lower limb alignment including tibial torsion and valgus/varus alignment were assessed by an EOS biplaner X-ray system with participants in weight-bearing position. Lower limb kinematics during gait was captured using the Vicon motion analysis system. The associations were estimated by partial Pearson correlation coefficient test. RESULTS: Our results indicated that external tibial torsion was related to early stance knee flexion excursion in participants with moderate knee OA (r = -0.58, p = 0.048), but not in participants with mild knee OA (r = 0.34, p = 0.102). External tibial torsion was associated with external foot progression angle (r = 0.48, p = 0.001), and knee varus/valgus alignment was associated with knee flexion excursion (r = -0.39, p = 0.010) in all participants. CONCLUSIONS: Both horizontal and frontal lower limb alignments were associated with knee flexion excursion at early stance of gait cycle in participants with medial knee OA. The distal rotational profile of lower limb would likely affect knee motion in sagittal plane. It implies that people with moderate knee OA could possibly benefit from correction of rotational alignment of lower limb.

Evidence for a personalized early start of norepinephrine in septic shock.

During septic shock, vasopressor infusion is usually started only after having corrected the hypovolaemic component of circulatory failure, even in the most severe patients. However, earlier administration of norepinephrine, simultaneously with fluid resuscitation, should be considered in some cases. Duration and depth of hypotension strongly worsen outcomes in septic shock patients. However, the response of arterial pressure to volume expansion is inconstant, delayed, and transitory. In the case of profound, life-threatening hypotension, relying only on fluids to restore blood pressure may unduly prolong hypotension and organ hypoperfusion. Conversely, norepinephrine rapidly increases and better stabilizes arterial pressure. By binding venous adrenergic receptors, it transforms part of the unstressed blood volume into stressed blood volume. It increases the mean systemic filling pressure and increases the fluid-induced increase in mean systemic filling pressure, as observed in septic shock patients. This may improve end-organ perfusion, as shown by some animal studies. Two observational studies comparing early vs. later administration of norepinephrine in septic shock patients using a propensity score showed that early administration reduced the administered fluid volume and day-28 mortality. Conversely, in another propensity score-based study, norepinephrine administration within the first hour following shock diagnosis increased day-28 mortality. The only randomized controlled study that compared the early administration of norepinephrine alone to a placebo showed that the early continuous administration of norepinephrine at a fixed dose of 0.05 µg/kg/min, with norepinephrine added in open label, showed that shock control was achieved more often than in the placebo group. The choice of starting norepinephrine administration early should be adapted to the patient's condition. Logically, it should first be addressed to patients with profound hypotension, when the arterial tone is very low, as suggested by a low diastolic blood pressure (e.g. ≤ 40 mmHg), or by a high diastolic shock index (heart rate/diastolic blood pressure) (e.g. ≥ 3). Early administration of norepinephrine should also be considered in patients in whom fluid accumulation is likely to occur or in whom fluid accumulation would be particularly deleterious (in case of acute respiratory distress syndrome or intra-abdominal hypertension for example).

Longitudinal monitoring reveals the emergence and spread of blaGES-5-harboring carbapenem-resistant Klebsiella quasipneumoniae in a Hong Kong hospital wastewater discharge line.

Testing hospital wastewater (HWW) is potentially an effective, long-term approach for monitoring trends in antimicrobial resistance (AMR) patterns in health care institutions. Over a year, we collected wastewater samples from the clinical and non-clinical sites of a tertiary hospital and from a downstream wastewater treatment plant (WWTP). We focused on the extent of carbapenem resistance among Enterobacteriaceae isolates given their clinical importance. Escherichia coli and Klebsiella spp. were the most frequently isolated Enterobacteriaceae species at all sampling sites. Additionally, a small number of isolates belonging to ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species), except K. pneumoniae, were detected. Of the 232 Klebsiella spp. isolates, 100 (43.1 %) were multi-drug resistant (MDR), with 46 being carbapenem-resistant. Most of these carbapenem-resistant isolates were K. quasipneumoniae (CRKQ) (n = 44). All CRKQ isolates were isolated from the wastewater of a clinical site that includes intensive care units, which also yielded significantly more multi-drug resistant isolates compared to all other sampling sites. Among the CRKQ isolates, blaGES-5 genes (n = 42) were the primary genetic determinant of carbapenem resistance. Notably, three different CRKQ isolates, collected within the same month in HWW and the influent and effluent flow of the WWTP, shared >99 % sequence similarity between their blaGES-5 genes and between their flanking regions and upstream integron-integrase region. The influent isolate was phylogenetically close to K. quasipnuemoniae isolates from wastewater collected in Japan. Its blaGES-5 gene and surrounding sequences were > 99 % identical to blaGES-24 genes found in the Japanese isolates. Our results suggest that testing samples from sites located closer to hospitals could support antibiotic stewardship programs compared to samples collected further downstream. Moreover, testing samples collected regularly from WWTPs may reflect the local and global spread of pathogens and their resistances.