Patient-Controlled Analgesia and Peripheral Nerve Block Increase the Risk of Post-operative Urinary Retention after Total Knee Arthroplasty in Asian Patients.

Introduction: Post-operative urinary retention (POUR) is a common complication after total knee arthroplasty (TKA) and may result in severe complications such as urinary tract infection and deep joint sepsis, leading to prolonged hospital stay and increased medical costs. Hence a retrospective study was performed to identify the incidence and modifiable factors associated with POUR after elective TKA in Asian patients with the aim to prevent POUR and its undesirable consequences. Materials and Methods: The medical records of 496 consecutive patients who underwent elective TKA between 1 August 2017 and 30 July 2018 were reviewed. There were 154 male (31.0%) and 342 female (69.0%) patients with an average age of 68 years old. The incidence of POUR was analysed with respect to various modifiable and non-modifiable risk factors, including patient demographics, medical comorbidities, duration of surgery, type of intra-operative anaesthesia and post-operative analgesia and early initiation of physiotherapy using univariate and multivariate analyses. Results: A total of 120 (24.2%) of the 496 patients who underwent elective TKA developed POUR. The odds of a patient with patient-controlled analgesia (PCA) and peripheral nerve block (PNB) developing POUR were 4.2 times and 4.7 times that of a patient without PCA and PNB, respectively. Age, male gender and type of anaesthesia were not found to be significant. Conclusion: In our study population, the incidence of POUR after elective TKA was 24% with major modifiable risk factors being associated with the use of PCA and PNB as post-operative anaesthesia. POUR can have deleterious effects thus alternative post-operative analgesia should be considered.

Access to COVID-19 vaccination by socio-economic status in older Singaporean adults: a population-based cohort study.

OBJECTIVES: Socio-economic status (SES) disparities exist in the uptake of COVID-19 vaccination; however, most studies were conducted during the initial pandemic wave when vaccination was less discretionary, limiting generalizability. We aimed to determine whether differences in vaccination uptake across SES strata widened after the removal of vaccination-differentiated measures prior to the rollout of the second boosters, in a nationwide cohort of older Singaporeans at higher risk of severe-COVID-19. STUDY DESIGN: Retrospective population-based cohort study. METHODS: Retrospective population-based cohort study of all Singaporeans aged ≥60 years from 22nd February 2021-14th February 2023. Cox regression models controlling for demographics and comorbidities were used to estimate hazard-ratios (HRs) for the uptake of primary vaccination as well as first/second boosters, as recorded in the national vaccination registry, according to SES (housing type). RESULTS: 836,170 individuals were included for completion of a primary vaccine series; 784,938 individuals for completion of the first booster and 734,206 individuals for the completion of the second booster. Differences in vaccination uptake by SES strata were observed (e.g. vaccination uptake in lowest-SES [1-2 room public-housing] versus highest-SES [private housing]: second booster, 47.6% vs. 58.1%; first booster, 93.9% vs. 98.0%). However, relative differences did not markedly widen during second booster rollout when vaccination was more discretionary (e.g. amongst those aged 60-69 years: 0.75 [95% CI = 0.73-0.76] for the first booster; 0.81 [95% CI = 0.79-0.84] for the second booster). CONCLUSION: While differences in vaccination uptake across SES strata by housing type persisted during the rollout of primary vaccination and subsequent boosters in a nationwide cohort of older Singaporeans, differences did not widen substantially when vaccination was made more discretionary.

MXene-based novel nanocomposites doped SnO2 for boosting the performance of perovskite solar cells.

Since being first published in 2018, the use of two-dimensional MXene in solar cells has attracted significant interest. This study presents, for the first time, the synthesis of an efficient hybrid electrocatalyst in the form of a nanocomposite (MXene/CoS)-SnO2 designed to function as a high-performance electron transfer layer (ETL). The study can be divided into three distinct parts. The first part involves the synthesis of single-layer Ti3C2Tx MXene nanosheets, followed by the preparation of a CoS solution. Subsequently, in the second part, the fabrication of MXene/CoS heterostructure nanocomposites is carried out, and a comprehensive characterization is conducted to evaluate the physical, structural, and optical properties. In the third part, the attention is on the crucial characterizations of the novel nanocomposite-electron transport layer (ETL) solution, significantly contributing to the evolution of perovskite solar cells. Upon optimising the composition, an exceptional power conversion efficiency of more than 17.69% is attained from 13.81% of the control devices with fill factor (FF), short-circuit current density (Jsc), and open-circuit voltage (Voc) were 66.51%, 20.74 mA/cm2, and 1.282 V. Therefore, this PCE is 21.93% higher than the control device. The groundbreaking MXene/CoS (2 mg mL-1) strategy reported in this research represents a promising and innovative avenue for the realization of highly efficient perovskite solar cells.

Impact of elevated IgE in protective immunity and immunopathology of dengue.

Dengue is a mosquito-transmitted infection endemic in tropical and subtropical locations of the world where nearly half of the world's population resides. The disease may present as mild febrile illness to severe and can even be fatal if untreated. There are four genetically related but antigenically distinct dengue virus (DENV) serotypes. Immune responses to DENV infection are in general protective but under certain conditions, they can also aggravate the disease. The importance of the cellular immune responses and the antibody responses involving IgG and IgM has been well-studied. In contrast, not much has been described on the potential role of hypersensitivity reactions involving IgE in dengue. Several studies have shown elevated levels of IgE in patients with dengue fever, but its involvement in the immune response against the virus and disease is unknown. Activation of mast cells (MCs) and basophils mediated through dengue-specific IgE could result in the release of mediators affecting dengue virus infection. The present review explores the relationships between the induction of IgE in dengue virus infection, and the potential role of MCs and basophils, exploring both protective and pathogenic aspects, including antibody-dependent enhancement (ADE) of infection in dengue.

Modulation of the microRNA-6089/E2F transcription factor2 axis by querceting: implications for osteoblast viability, proliferation, migration, and osteogenic differentiation in fracture healing.

Quercetin is widely distributed in plants as a flavonol compound with multiple biological activities. It has been found that quercetin can regulate bone homeostasis through multiple pathways and targets. This study investigated the role and specific molecular mechanisms of quercetin in regulating osteoblast viability, proliferation, migration and osteogenic differentiation. A mouse model of traumatic fracture was established and then 100 mg/kg quercetin corn oil suspension was gavaged at the same time every day for 28 days. miR-6089 and E2F transcription factor 2 (E2F2) expression levels in mice were measured. Fracture healing in mice was observed. MC3T3-E1 cells were transfected with plasmids targeting miR-6089 and E2F2, and cell viability, proliferation, migration, apoptosis, and osteogenic differentiation were determined. The targeting relationship between miR-6089 and E2F2 was verified. In vivo experiments showed that quercetin significantly increased osteocalcin (OCN) expression (P<0.05) and promoted fracture healing in traumatic fracture (TF) mice. miR-6089 expression was down-regulated (P<0.05) and E2F2 expression was up-regulated (P<0.05) in TF mice. Quercetin promoted miR-6089 expression and inhibited E2F2 expression (both P<0.05). In vitro results showed that quercetin promoted miR-6089 expression and inhibited E2F2 expression in a dose-dependent manner (both P<0.05). Quercetin dose-dependently promoted MC3T3-E1 cell viability, proliferation, migration, and osteogenic differentiation, and inhibited MC3T3-E1 cell apoptosis (all P<0.05). Up-regulating miR-6089 further promoted MC3T3-E1 cell viability, proliferation, migration and osteogenic differentiation, and inhibited MC3T3-E1 cell apoptosis (all P<0.05). miR-6089 targeted and regulated E2F2 expression. Up-regulating E2F2 attenuated the promoting effect of up-regulated miR-6089 on MC3T3-E1 cell viability, proliferation, migration, osteogenic differentiation, and inhibition of apoptosis (all P<0.05). We conclude that quercetin enhances osteoblast viability, proliferation, migration, and osteogenic differentiation by modulating the miR-6089/E2F2 axis, thereby promoting fracture healing.

Identification of genomic regions associated with differences in fleece type in Huacaya and Suri alpacas (Vicugna pacos).

The difference in fleece type is the distinguishing trait between the two types of alpacas (Vicugna pacos), Huacaya and Suri. The Suri fleece type has been found to be inherited dominantly over the Huacaya type, resulting in offspring with the Suri phenotype. The aim of our study was to map genomic regions associated with the two different fleece types. In this study, 91 alpacas (54 Huacayas and 37 Suris) from Germany and Switzerland were genotyped using the 76k alpaca SNP array. Only 59k chromosome-localised markers map to the alpaca reference assembly VicPac3.1, and after quality control 49 866 SNPs, were retained for population structure assessment and to conduct a genome-wide association study. Both principal component and neighbour-joining tree analysis showed that the two fleece-type cohorts overlapped rather than forming two distinct clusters. Genome-wide significantly associated markers were observed in the scaffold region of chromosome 16 (NW_021964192.1), which contains a cluster of keratin genes. A haplotype predominantly found in Suri alpacas has been identified which supports dominant inheritance. Variant filtering of nine whole-genome sequenced alpacas from both fleece types in the critical interval of 0.4 Mb did not reveal perfect segregation of either fleece type for specific variants. To our knowledge, this is the first study to use the recently developed species-specific SNP array to identify genomic regions associated with differences in fleece type in alpacas. There are still some limitations, such as the preliminary status of the reference assembly and the incomplete annotation of the alpaca genome.

Development of an online animated sexting prevention module based on the prototype willingness model to reduce intention and willingness to sexting among diploma students.

INTRODUCTION: Sexting refers to the act of sending and receiving sexually explicit content in the form of in the form of texts, photos, or videos via the Internet and mobile phones. This behaviour is associated with many negative health consequences among young people. However, there is a lack of intervention studies to curb this behaviour. We have developed a new sexting prevention module and tested it using a randomised controlled field trial. This paper reported the phase one of the study i.e., the development of an animated sexting prevention module using the prototype willingness model (PWM) to reduce the intention and willingness to sext amongst diploma students in Malaysia. MATERIALS AND METHOD: The initial phase involved a review of previous interventions, validation from field experts, and the process of developing video. Then the module pilot was tested among 30 diploma students from a public university. They were given access to the newly developed videos posted on a private YouTube channel and asked to evaluate the videos quantitatively and qualitatively by using the acceptability of the intervention module (AIM), intervention appropriateness measure (IAM) and feasibility of the intervention measure (FIM). The minimum and maximum scores of each measure were 12 and 24 respectively whereby a higher score indicated greater acceptability, appropriateness and feasibility. RESULTS: The intervention consisted of five sections addressing the constructs of PWM, namely attitude, perceived norm, prototype perception, as well as intention and willingness of sexting. The contents were then converted into five videos with a total duration of 23 minutes. Based on the pilot test, the scores of AIM, IAM and FIM were not normally distributed and their median and the interquartile range values were 20 (4), 21 (4) and 22 (4) respectively. Most of the respondents gave favourable opinions on the intervention besides providing some input for improvement. CONCLUSION: This animated sexting intervention module based on PWM to reduce the intention and willingness was novel. The module was acceptable, appropriate and feasible to be implemented among undergraduate students. Further evaluation of this intervention module can be performed to provide more comprehensive evidence of its effectiveness.

Dientamoeba fragilis associated with microbiome diversity changes in acute gastroenteritis patients.

This study examined the correlation between intestinal protozoans and the bacterial microbiome in faecal samples collected from 463 patients in New Zealand who were diagnosed with gastroenteritis. In comparison to traditional microscopic diagnosis methods, Multiplexed-tandem PCR proved to be more effective in detecting intestinal parasites. Among the identified protozoans, Blastocystis sp. and Dientamoeba fragilis were the most prevalent. Notably, D. fragilis was significantly associated with an increase in the alpha-diversity of host prokaryotic microbes. Although the exact role of Blastocystis sp. and D. fragilis as the primary cause of gastroenteritis remains debatable, our data indicates a substantial correlation between these protozoans and the prokaryote microbiome of their hosts, particularly when compared to other protists or patients with gastroenteritis but no detectable parasitic cause. These findings underscore the significance of comprehending the contributions of intestinal protozoans, specifically D. fragilis, to the development of gastroenteritis and their potential implications for disease management.

Contamination of the central medical air supply with water leading to mass ventilator failure.

Here, we present a case of mass ventilator failure due to contaminated medical air. Multiple ventilators failed routine tests, including almost all of the ventilators in our intensive care unit. A faulty air compressor had led to water contamination of our centre's supply of medical air. Water entered the pipeline supply of air and, hence the ventilators and anaesthetic machines. The disruption of the machines' proportional mixer valve resulted in unreliable delivery of fresh gas flow. This malfunction was discovered during routine pre-use checks, and backup ventilators were available to replace the faulty ventilators. A shortage of equipment was averted due to a serendipitous availability of ventilator stockpiles prepared for the COVID-19 pandemic. Ventilator shortages are commonly described in mass casualty and pandemic scenarios. While there are multiple strategies described in literature to augment and maximise equipment available for mechanical ventilation, stockpiling equipment remains an expensive but necessary component of disaster contingency planning.

Fibreglass dermatitis: diagnostic challenges and occupational interventions.

Fibreglass dermatitis is a common occupationally acquired irritant contact dermatitis, where small spicules of fibreglass lodging in the stratum corneum result in mechanical irritation. We present two patients, an air-conditioning ducting worker and an injection moulding machine operator, who both presented with generalized pruritus. In the first case, polarized microscopy of a skin biopsy specimen demonstrated rare small spicules, with a diameter of 1 µm, lodged in the stratum corneum. In the second case, skin tape stripping demonstrated fibreglass particles, not found on skin biopsy. Proper work practices, personal hygiene and use of impervious barrier materials were recommended. The first patient did not return for follow-up, and the second patient's dermatitis resolved after handling of fibreglass-containing material was eliminated from his job scope. In conclusion, we present two cases of fibreglass dermatitis to illustrate the challenges in diagnosis and highlight strategies for prevention.

Comorbidities in newly diagnosed epilepsy: Pre-existing health conditions are common and complex across age groups.

OBJECTIVES: People with epilepsy have a higher prevalence of medical and psychiatric comorbidities compared to the general population. Comorbidities are associated with poor epilepsy outcomes, and there have been recommendations for screening and early identification to improve clinical management. Data from 'First Seizure Clinics' (FSCs) with expert epileptological review can inform about disorders already present at the point of diagnosis of epilepsy or unprovoked seizures. Here, we aimed to describe pre-existing conditions with a focus on psychiatric, substance use, cardiac, neurological, and cancer health domains. METHODS: We included 1383 adults who received a new diagnosis of epilepsy or unprovoked seizures at Austin Hospital (AH) or Royal Melbourne Hospital (RMH) (Australia) FSCs from 2000 to 2010. Data were audited from FSC records, primarily detailed interviews undertaken by epileptologists. Logistic regression examined age distribution and other risk factors. RESULTS: The median age at FSC presentation was 37 years (IQR 26-53, range 18-94). Pre-existing conditions were reported by 40 %; from 32 % in the youngest group (18-30 years) to 53 % in the oldest (65+ years). Psychiatric (18 %) and substance use (16 %) disorders were most common, with higher prevalence among patients 18 to 65 years of age compared to those older than 65 years (p < 0.001). Cardiac, neurological, or cancer conditions were reported by 3-6 %, most often amongst those older than 65 years (p < 0.01). Eight percent (n = 112) reported disorders in >1 health domain. The commonest combination was a psychiatric condition with substance use disorder. Of the sixty-two patients reporting this combination, 61 were ≤65 years of age. CONCLUSIONS: Pre-existing health conditions are present in a substantial proportion of patients diagnosed with epilepsy or unprovoked seizures. Disorders are highest amongst elders, but one-third of younger adults also reported positive histories. These are predominantly psychiatric and/or substance use disorders, conditions strongly associated with poor outcomes in the general population. These findings inform post-diagnosis planning and management, as well as research examining post-diagnostic outcomes and associations between comorbidities and epilepsy.

Clinical severity of COVID-19 with omicron variant predominance in relation to vaccination status, age, comorbidities- a single center in Selangor, Malaysia.

INTRODUCTION: Recently, the rapid surge of reported COVID-19 cases attributed to the Omicron variant of severe acute respiratory syndrome coronavirus (SARS-CoV-2) created an immediate concern across nations. Local information pertaining to the new variant of concern (VOC) is lacking. We aimed to determine the clinical characteristics of COVID-19 during a period of Omicron prevalence among patients hospitalised from February 1 to 21, 2022 at Sungai Buloh Hospital and to estimate the risks of disease progression presumably caused by this variant in association with gender, age, comorbidity, and vaccination status. MATERIALS AND METHODS: In this retrospective, singlecentered, retrospective cohort study, all hospitalised adults with laboratory-confirmed COVID-19, aged 18 and above, were recruited from February 1 to 21, 2022. Clinical characteristics, investigations, and outcomes were assessed. RESULTS: A total of 2279 patients aged 18 years and above with laboratory-proven COVID-19 were recruited and analysed, excluding 32 patients owing to incomplete data. Majority of the study population had a mean age of 41.8 ± 17.7, was female-predominant (1329/2279, 58.6%), had completed a primary series of vaccination with a booster (1103/2279, 48.4%), and had no underlying medical conditions (1529/2279, 67.4%). The risk of COVID-19-related disease progression was significantly lower in hospitalised patients under the age of 50 who were female, had no comorbidity, and had completed two doses of the primary series with or without a booster. [respectively, OR 7.94 (95% CI 6.16, 10.23); 1.68 (1.34, 2,12); 2.44 (1.85, 3.22); 2.56 (1.65, 3.97), p< 0.001]. CONCLUSION: During the period of Omicron prevalence, a favourable outcome of COVID-19 was strongly associated with female gender, age below 50, a comorbidity-free condition, and having completed immunization. With this new observation, it could help improve public health planning and clinical management in response to the emergence of the latest VOC.

A quality improvement project: Reducing bloodstream infection by improving adherence to the care bundle of peripheral vascular catheters at the COVID-19 treatment centre.

INTRODUCTION: During the COVID-19 pandemic, bloodstream infection (BSI) rates were substantially rising in Sungai Buloh Hospital (HSB). It is believed that the COVID-19 pandemic has had an adverse impact on BSI incidence caused by contaminated periphery vascular catheters (PVCs). The study's objective is to reduce the BSI rates in HSB by improving adherence to the PVC care bundle via the Plan-Do-Study-Act (PDSA) approach. MATERIALS AND METHODS: A quality improvement (QI) project was employed over four months, from June to September 2021, during the COVID-19 pandemic in HSB. All adults hospitalised for COVID-19 with intravenous lines were subjected to data collection. A baseline audit was conducted to study BSI incidence from April to May 2021. Implementation was carried out by PDSA cycles and data on BSI rates per 100 admissions was described using a monthly run chart. RESULTS: At baseline, the BSI rate per 100 admissions was 5.44 before implementing our QI project. Initial changes via PDSA cycles did not bring significant improvements to BSI rates and a rising trend in BSI rates was observed after two PDSA cycles. Further audits identified the problem of noncompliance with the practice of aseptic non-touch technique (ANTT) and a lack of effective leadership in implementing the PVC care bundle. The third PDSA cycle focused on adopting practical leadership skills among senior clinicians to ensure compliance with the prevention bundle and to encourage the use of ultrasound guidance for difficult line insertion. After the third PDSA cycle, the BSI rate per 100 admissions was reduced from 6.41 to 4.34 (p < 0.05). The BSI rates continued to decline down the line for another five months. CONCLUSION: Through QI initiatives, the risk of BSI can be significantly reduced.

Developing high intensity ultrasonic cleaning (HIUC) for post-processing additively manufactured metal components.

The high energy phenomenon of cavitation bubble collapses has enabled numerous applications, including cleaning. In ultrasonic cleaning, cavitation intensity is typically lower than in other applications, such as sonochemistry and material processing. However, there has been an emerging application in intense cleaning of metal additively manufactured (AM) components. The presence of partially melted powders on AM surfaces is undesirable, contributing to high surface roughness and posing contamination risks during usage. We designed a high-intensity cavitation cleaning process that has significantly higher inertial cavitation intensity - i.e., erosion potential - than a conventional ultrasonic cleaning tank. Through acoustic signal characterisation, we showed that placing transducer sets on four sides of the tank could effectively focus and generate high-amplitude pressure waves directed towards the central region. Strong subharmonic signals indicate intensely inertial cavitation throughout the tank. Cavitation intensities were measured at various locations to understand the wave transmission characteristics and distribution patterns. Our results show that the cavitation intensity distribution is highly dependent on the height position. Finally, we demonstrated that the high intensity ultrasonic cleaning (HIUC) process could remove partially melted powders from an AM surface - which was not possible through conventional ultrasonic cleaning. HIUC could lead to higher cleaning efficiency and enhanced AM specimen cleanliness.

Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management.

In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up. A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received. Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident. Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

Development of a prediction score (ThyroCOVID) for identifying abnormal thyroid function in COVID-19 patients.

PURPOSE: Thyroid dysfunction in COVID-19 carries clinical and prognostic implications. In this study, we developed a prediction score (ThyroCOVID) for abnormal thyroid function (TFT) on admission amongst COVID-19 patients. METHODS: Consecutive COVID-19 patients admitted to Queen Mary Hospital were prospectively recruited during July 2020-May 2021. Thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) were measured on admission. Multivariable logistic regression analysis was performed to identify independent determinants of abnormal TFTs. ThyroCOVID was developed based on a clinical model with the lowest Akaike information criteria. RESULTS: Five hundred and forty six COVID-19 patients were recruited (median age 50 years, 45.4% men, 72.9% mild disease on admission). 84 patients (15.4%) had abnormal TFTs on admission. Patients with abnormal TFTs were more likely to be older, have more comorbidities, symptomatic, have worse COVID-19 severity, higher SARS-CoV-2 viral loads and more adverse profile of acute-phase reactants, haematological and biochemical parameters. ThyroCOVID consisted of five parameters: symptoms (malaise), comorbidities (ischaemic heart disease/congestive heart failure) and laboratory parameters (lymphocyte count, C-reactive protein, and SARS-CoV-2 cycle threshold values). It was able to identify abnormal TFT on admission with an AUROC of 0.73 (95% CI 0.67-0.79). The optimal cut-off of 0.15 had a sensitivity of 75.0%, specificity of 65.2%, negative predictive value of 93.5% and positive predictive value of 28.1% in identifying abnormal TFTs on admission amongst COVID-19 patients. CONCLUSION: ThyroCOVID, a prediction score to identify COVID-19 patients at risk of having abnormal TFT on admission, was developed based on a cohort of predominantly non-severe COVID-19 patients.

Ordering of computed tomography scans for head and cervical spine: a qualitative study exploring influences on doctors' decision-making.

BACKGROUND: Ordering of computed tomography (CT) scans needs to consideration of diagnostic utility as well as resource utilisation and radiation exposure. Several factors influence ordering decisions, including evidence-based clinical decision support tools to rule out serious disease. The aim of this qualitative study was to explore factors influencing Emergency Department (ED) doctors' decisions to order CT of the head or cervical spine. METHODS: In-depth semi-structured interviews were conducted with purposively selected ED doctors from two affiliated public hospitals. An interview tool with 10 questions, including three hypothetical scenarios, was developed and validated to guide discussions. Interviews were audio recorded, transcribed verbatim, and compared with field notes. Transcribed data were imported into NVivo Release 1.3 to facilitate coding and thematic analysis. RESULTS: In total 21 doctors participated in semi-structured interviews between February and December 2020; mean interview duration was 35 min. Data saturation was reached. Participants ranged from first-year interns to experienced consultants. Five overarching emerging themes were: 1) health system and local context, 2) work structure and support, 3) professional practices and responsibility, 4) reliable patient information, and 5) holistic patient-centred care. Mapping of themes and sub-themes against a behaviour change model provided a basis for future interventions. CONCLUSIONS: CT ordering is complex and multifaceted. Multiple factors are considered by ED doctors during decisions to order CT scans for head or c-spine injuries. Increased education on the use of clinical decision support tools and an overall strategy to improve awareness of low-value care is needed. Strategies to reduce low-yield CT ordering will need to be sustainable, sophisticated and supportive to achieve lasting change.

Diagnostic delay in focal epilepsy: Association with brain pathology and age.

PURPOSE: Between 16-77% of patients with newly diagnosed epilepsy report seizures before diagnosis but little is known about the risk factors for diagnostic delay. Here, we examined the association between prior seizures and neuroimaging findings in newly diagnosed focal epilepsy. METHODS: Adults diagnosed with focal epilepsy at First Seizure Clinics (FSC) at the Royal Melbourne Hospital or Austin Health, Melbourne, Australia, between 2000 and 2010 were included. Medical records were audited for seizure history accrued from the detailed FSC interview. Potentially epileptogenic brain abnormality type, location and extent was determined from neuroimaging. Statistical analysis comprised multivariate logistic regression. RESULTS: Of 735 patients, 44% reported seizure/s before the index seizure. Among the 260 individuals with a potentially epileptogenic brain imaging abnormality, 34% reported prior seizures. Of 475 individuals with no abnormality, 50% reported prior seizures (p < 0.001). Patients with post-stroke changes had lower odds of prior seizures (n = 24/95, OR 0.5, p = 0.005) compared to patients without abnormalities, as did patients with high-grade tumors (n = 1/10, OR 0.1, p = 0.04). Abnormality location or extent was not associated with seizures. Prior seizures were inversely associated with age, patients aged >50 years had lower odds compared to those 18-30 years (OR 0.5, p = 0.01). CONCLUSIONS: A history of prior seizures is less common in patients with newly diagnosed focal epilepsy associated with antecedent stroke or high-grade tumor than in those without a lesion, and is also less common in older individuals. These findings may be related to age, biological mechanisms or aspects of diagnosis and assessment of these events.

The marginal gaps of sequentially milled lithium disilicate crowns using two different milling units.

BACKGROUND: The purpose of this study was to compare the marginal gaps of sequentially milled lithium disilicate (LDS) crowns using two different milling units. METHODS: One lower left first molar typodont tooth prepared for an LDS crown by an undergraduate student in a simulation clinic was selected. The crown preparation was scanned by a TRIOS 3 scanner and twelve LDS crowns milled by an E4D (E4DM) and a Sirona inLab MC X5 (MCX5) milling unit using identical settings. The crowns were seated onto the original crown preparation and three vertical marginal gap measurements were taken at four locations (mid-buccal, mid-lingual, mid-mesial and mid-distal) using a stereomicroscope. The mean marginal gap (MMG) was calculated for each individual tooth surface and each crown. RESULTS: The MMG for the E4DM (100.40 µm) was not significantly different to the MCX5 (101.08 µm) milling unit (P = 0.8809). In both units, there was a statistically significant trend of increasing MMG with sequentially milled crowns using the same burs (E4DM P = 0.0133; MCX5 P = 0.0240). CONCLUSIONS: The E4DM and MCX5 milling units produced LDS crowns with similar MMG's and within a clinically acceptable range but with a trend of increasing MMG when analysed sequentially. © 2022 Australian Dental Association.