Fracture incidence and fracture-related mortality decreased with decreases in population mobility during the early days of the COVID-19 pandemic: an epidemiological study.

INTRODUCTION: We investigated the impact of coronavirus disease 2019 (COVID-19) social distancing measures on fracture incidence and fracture-related mortality, as well as associations with population mobility. METHODS: In total, 47 186 fractures were analysed across 43 public hospitals from 22 November 2016 to 26 March 2020. Considering the smartphone penetration of 91.5% in the study population, population mobility was quantified using Apple Inc's Mobility Trends Report, an index of internet location services usage volume. Fracture incidences were compared between the first 62 days of social distancing measures and corresponding preceding epochs. Primary outcomes were associations between fracture incidence and population mobility, quantified by incidence rate ratios (IRRs). Secondary outcomes included fracture-related mortality rate (death within 30 days of fracture) and associations between emergency orthopaedic healthcare demand and population mobility. RESULTS: Overall, 1748 fewer fractures than projected were observed during the first 62 days of COVID-19 social distancing (fracture incidence: 321.9 vs 459.1 per 100 000 person-years, P<0.001); the relative risk was 0.690, compared with mean incidences during the same period in the previous 3 years. Population mobility exhibited significant associations with fracture incidence (IRR=1.0055, P<0.001), fracture-related emergency department attendances (IRR=1.0076, P<0.001), hospital admissions (IRR=1.0054, P<0.001), and subsequent surgery (IRR=1.0041, P<0.001). Fracture-related mortality decreased from 4.70 (in prior years) to 3.22 deaths per 100 000 person-years during the COVID-19 social distancing period (P<0.001). CONCLUSION: Fracture incidence and fracture-related mortality decreased during the early days of the COVID-19 pandemic; they demonstrated significant temporal associations with daily population mobility, presumably as a collateral effect of social distancing measures.

The Common Missed Handwashing Instances and Areas after 15 Years of Hand-Hygiene Education.

The outbreak of severe acute respiratory syndrome (SARS) claimed the lives of 286 Hong Kong people in 2003. Since then, the Hong Kong government has been promoting the benefits of proper hand hygiene. There are few studies that explore the general quality of handwashing and the hand-hygiene practices of the public of Hong Kong; given this, the aim of this study is to explore this neglected topic. This study is a quantitative study that was conducted in January 2018. The results show that the majority of participants only wash their hands after using the toilet (87%) or handling vomitus or faecal matter (91%). The mean duration of handwashing was 36.54 seconds (SD = 18.57). The areas of the hand most neglected during handwashing were the fingertips (48.1%), medial area (30.5%), and back of the hand (28%). A multiple logistic regression shows that participants who have reached third-level education or higher often tend to be more hand hygienic than those who have not reached third-level education (p ≤ 0.001, B = 1.003). Thus, participants aged 30 and above tend to neglect 5 more areas of the hand than those aged below 30 (p=0.001, B = 4.933).

Elastohydrodynamic lubricant flow with nanoparticle tracking.

Lubricants operating in elastohydrodynamic (EHD) contacts exhibit local variations in rheological properties when the contact pressure rises. Direct evidence of this behaviour has only been obtained by examining through-thickness velocity profiles U(z) of lubricants in a contact using luminescence-based imaging velocimetry. In the present study, nanoparticles (NPs) are added to polybutene (PB) as tracers to investigate the effect of pressure on the flow of PB in an EHD contact. By tracking NPs in the contact, particle velocity distributions f(U) under various pressures are obtained and found to be pressure dependent. Results show quantitatively that f(U) and U(z) are correlated and thus confirm that U(z) of PB changes from Couette flow to partial plug flow above a critical pressure. This confirmation highlights the complexity of lubricant rheology in a high pressure contact.

Comparing the molecular and global rheology of a fluid under high pressures.

The viscosity of liquids is a strong function of pressure. While viscosity is relatively easy to measure at low pressure, high-pressure rheology presents significant experimental challenges. As a result, rheological models are often used to extrapolate viscosity from low pressure measurements to higher pressures. Techniques to obtain data over a wide range of pressures and shear rates, as well as understanding the validity and limitations of methods to fill the gaps in the available data, are therefore of crucial practical and theoretical importance. This work examines the viscosity of polyalphaolefin (PAO) by combining average global area averaged measurements at high pressure and local molecular viscosity measurements at moderate pressures. Viscosities spanning five orders of magnitude are examined at pressures up to 720 MPa. High pressure results were obtained with friction measurements where the fluid is sheared between two surfaces in a loaded point contact. The local molecular microviscosity at medium and low pressures was measured by applying a technique based on fluorescence anisotropy, which probes the rotational motion of dye molecules in a nanoscale film under shear. Both sets of measurements are taken in the same configuration, an elastohydrodynamic (EHD) contact. This is the first set of quantitative local viscosity measurements that have been verified against both friction and high pressure rheometry measurements. Commonly used rheological models were compared to experimental results. Our work shows that fluorescence anisotropy and friction measurements can be used to determine the viscosity of liquids over a wide range of conditions from a single experimental setup. The results obtained match results from low- and high-pressure rheometry for PAO. The importance of correcting friction data for pressure non-uniformity, temperature and shear thinning is also highlighted.

Quantitative Viscosity Mapping Using Fluorescence Lifetime Measurements.

Lubricant viscosity is a key driver in both the tribological performance and energy efficiency of a lubricated contact. Elastohydrodynamic (EHD) lubrication produces very high pressures and shear rates, conditions hard to replicate using conventional rheometry. In situ rheological measurements within a typical contact are therefore important to investigate how a fluid behaves under such conditions. Molecular rotors provide such an opportunity to extract the local viscosity of a fluid under EHD lubrication. The validity of such an application is shown by comparing local viscosity measurements obtained using molecular rotors and fluorescence lifetime measurements, in a model EHD lubricant, with reference measurements using conventional rheometry techniques. The appropriateness of standard methods used in tribology for high-pressure rheometry (combining friction and film thickness measurements) has been verified when the flow of EHD lubricant is homogeneous and linear. A simple procedure for calibrating the fluorescence lifetime of molecular rotors at elevated pressure for viscosity measurements is proposed.

Management of para-aortic lymph node metastasis in colorectal patients: A systemic review.

INTRODUCTION: Para-aortic lymph node (PALN) involvement occurs in up to 2% of colorectal cancer (CRC) patients. While resection for isolated hepatic and pulmonary metastases in colorectal cancer is standard practice, the role of PALN dissection (PALND) in CRC has not been established and remains a controversy. We aim to perform a systematic review of the literature to determine if extensive lymphadenectomy improves survival, and is an acceptable strategy for PALN metastasis (PALNM). MATERIALS AND METHODS: A systematic search of PubMed and Embase databases for studies reporting on patients with isolated PALNM in CRC was performed. Studies including patients with synchronous and metachronous PALN were included, and studies including patients with other metastases were excluded. RESULTS: Eighteen retrospective, single-centre studies were included in the final analysis. The reported incidence of isolated PALNM ranged from 1.3 to 1.7%. A total of 370 patients with PALNM were evaluated, of which 145 had synchronous, and 225 had metachronous PALNM. For synchronous PALNM, the 5-year overall survival (OS) after metastatectomy, ranged from 22.7% to 33.9%. For metachronous PALNM, the 5-year OS ranged from 15 to 60%; median OS was 34-40 months in the PALND versus 3-14 months for patients who did not undergo PALND. There were no reported surgery related mortalities, and overall surgical morbidity was 7.8-33%. CONCLUSION: PALND for isolated PALNM from colorectal cancer can be performed with minimal morbidity and confers a survival advantage, in comparison with conventional palliative chemotherapy or chemoradiation therapy.

Do measures of reactive balance control predict falls in people with stroke returning to the community?

OBJECTIVE: To determine if reactive balance control measures predict falls after discharge from stroke rehabilitation. DESIGN: Prospective cohort study. SETTING: Rehabilitation hospital and community. PARTICIPANTS: Independently ambulatory individuals with stroke who were discharged home after inpatient rehabilitation (n=95). MAIN OUTCOME MEASURES: Balance and gait measures were obtained from a clinical assessment at discharge from inpatient stroke rehabilitation. Measures of reactive balance control were obtained: (1) during quiet standing; (2) when walking; and (3) in response to large postural perturbations. Participants reported falls and activity levels up to 6 months post-discharge. Logistic and Poisson regressions were used to identify measures of reactive balance control that were related to falls post-discharge. RESULTS: Decreased paretic limb contribution to standing balance control [rate ratio 0.8, 95% confidence interval (CI) 0.7 to 1.0; P=0.011], reduced between-limb synchronisation of quiet standing balance control (rate ratio 0.9, 95% CI 0.8 to 0.9; P<0.0001), increased step length variability (rate ratio 1.4, 95% CI 1.2 to 1.7; P=0.0011) and inability to step with the blocked limb (rate ratio 1.2, 95% CI 1.0 to 1.3; P=0.013) were significantly associated with increased fall rates when controlling for age, stroke severity, functional balance and daily walking activity. CONCLUSIONS: Impaired reactive balance control in standing and walking predicted increased risk of falls post-discharge from stroke rehabilitation. Specifically, measures that revealed the capacity of both limbs to respond to instability were related to increased risk of falls. These results suggest that post-stroke rehabilitation strategies for falls prevention should train responses to instability, and focus on remediating dyscontrol in the more-affected limb.

Effect of aerobic exercise training on chinese population with mild to moderate depression in Hong Kong.

Background. Exercise has been suggested to be a viable treatment for depression. This study investigates the effect of supervised aerobic exercise training on depressive symptoms and physical performance among Chinese patients with mild to moderate depression in early in-patient phase. Methods. A randomized repeated measure and assessor-blinded study design was used. Subjects in aerobic exercise group received 30 minutes of aerobic training, five days a week for 3 weeks. Depressive symptoms (MADRS and C-BDI) and domains in physical performance were assessed at baseline and program end. Results. Subjects in aerobic exercise group showed a more significant reduction in depressive scores (MADRS) as compared to control (between-group mean difference = 10.08 ± 9.41; P = 0.026) after 3 weeks training. The exercise group also demonstrated a significant improvement in flexibility (between-group mean difference = 4.4 ± 6.13; P = 0.02). Limitations. There was lack of longitudinal followup to examine the long-term effect of aerobic exercise on patients with depression. Conclusions. Aerobic exercise in addition to pharmacological intervention can have a synergistic effect in reducing depressive symptoms and increasing flexibility among Chinese population with mild to moderate depression. Early introduction of exercise training in in-patient phase can help to bridge the gap of therapeutic latency of antidepressants during its nonresponse period.

Prevalence of asymptomatic atrial fibrillation in malaysian patients with hypertension.

Atrial fibrillation (AF) is usually asymptomatic and often associated with established cardiovascular risk factors such as hypertension. The prevalence atrial fibrillation in patients admitted to Malaysian hospitals has been determined, but asymptomatic atrial fibrillation (AAF) in hypertensive patients in the primary care setting is not established. This study reports the prevalence of AAF in hypertensive patients in Malaysia, in a primary care setting. The overall prevalence of AAF was 0.75% with no differences between the gender. The prevalence of AAF increases with age - in the age groups of 30-39, >40-49, >50-59, >60-69, 70-79 and >80 years old were 0%, 0.17%, 0.35%, 2.32%, 2.59%, and 0% respectively. Hypertensive patients with age of ≥ 61 year old were associated with a probability of 10.6 times higher for AAF. We suggest the age threshold to screen for AAF to be age of 60. It is estimated that there are 49,029 Malaysians with AAF in 2010. A large population is at risk of AAF-related complications. There is justification for an even greater emphasis on diagnostic, primary and secondary prevention strategies.

Adjuvant hepatic intra-arterial iodine-131-lipiodol following curative resection of hepatocellular carcinoma: a prospective randomized trial.

BACKGROUND: The purpose of the present study was to determine whether intrahepatic injection of (131)I-lipiodol (Lipiodol) is effective against recurrence of surgically resected hepatocellular carcinoma (HCC). METHODS: From June 2001 through March 2007, this nationwide multi-center prospective randomized controlled trial enrolled 103 patients 4-6 weeks after curative resection of HCC with complete recovery (52: Lipiodol, 51: Control). Follow-up was every 3 months for 1 year, then every 6 months. Primary and secondary endpoints were recurrence-free survival (RFS) and overall survival (OS), respectively, both of which were evaluated by the Kaplan-Meier technique and summarized by the hazard ratio (HR). The design was based on information obtained from a similar trial that had been conducted in Hong Kong. RESULTS: The Lipiodol group showed a small, and nonsignificant, improvement over control in RFS (HR = 0.75; 95 % confidence interval [95 % CI] 0.46-1.23; p = 0.25) and OS (HR = 0.88; 95 % CI 0.51-1.51; p = 0.64). Only two serious adverse events were reported, both with hypothyroidism caused by (131)I-lipiodol and hepatic artery dissection during angiography. CONCLUSIONS: The randomized trial provides insufficient evidence to recommend the routine use of (131)I-lipiodol in these patients.

Randomized clinical trial of open hepatectomy with or without intermittent Pringle manoeuvre.

BACKGROUND: The intermittent Pringle manoeuvre (IPM) is commonly applied during liver resection. Few randomized trials have addressed its effectiveness in reducing blood loss and the results have been conflicting. The present study investigated the hypothesis that IPM could reduce blood loss during liver resection by 50 per cent. METHODS: Between May 2008 and April 2011, patients who underwent elective open hepatectomy were randomized into an IPM or no Pringle manoeuvre (NPM) group and stratified according to the presence or absence of cirrhosis. Data on demographics, type of hepatectomy, operative blood loss, duration of operation, mortality, morbidity and postoperative liver function were recorded and analysed. The primary endpoint was operative blood loss. RESULTS: There were 63 patients in each group. Median (range) operative blood loss was 370 (50-3600) ml in the IPM group versus 335 (40-3160) ml in the NPM group (P = 1·000). There were no differences in blood loss in different phases of the operation, blood loss per area of liver transected or blood transfusion rate, nor in total duration of operation or liver transection time. Postoperative serum alanine aminotransferase levels were higher in the IPM group (P < 0·001). There were more postoperative complications in the IPM group (41 versus 24 per cent; P = 0·036). CONCLUSION: The IPM did not reduce blood loss, but was associated with raised levels of postoperative liver parenchymal enzymes and more complications. REGISTRATION NUMBER: NCT00730743 (http://www.clinicaltrials.gov).

Diagnosis of tuberculous lymphadenitis using fine needle aspiration biopsy.

BACKGROUND: Tuberculous lymphadenitis is the commonest form of extrapulmonary tuberculosis. However, the optimal approach to diagnosis, employing biopsy by either fine needle aspiration (FNA) or surgical excision, remains uncertain. AIMS: To evaluate the diagnostic value of biopsy using each of the component diagnostic modalities of FNA (microscopy, cytology and culture), and compare these with excision biopsy in the diagnosis of tuberculous lymphadenitis in a predominantly migrant population in Melbourne. METHODS: A retrospective examination of tuberculous lymphadenitis cases presenting to Western Health over 12 years was conducted. Using a reference method of positive culture of Mycobacterium tuberculosis, the diagnostic sensitivities of each modality employed in FNA were determined. RESULTS: Forty-two subjects having FNA and 30 having excision biopsy as the initial investigation were compared. Among specimens obtained by FNA, sensitivity of microscopy was 18% (95% confidence interval (CI): 5­40%) and sensitivity of cytology was 38% (95% CI: 20­59%). For specimens obtained by excision biopsies, sensitivities for microscopy and histology were 17% (95% CI: 2­32%) and 96% (95% CI: 88­100%) respectively. Sensitivity of culture performed on FNA specimens was 86% (95% CI: 65­97%). CONCLUSIONS: Given the relatively high sensitivity of mycobacterial cultures from FNA, this study supports its routine use as the initial investigation in most patients with suspected tuberculous lymphadenitis. Microscopy and cytology add relatively little to the clinical utility of FNA

Polymyositis and dermatomyositis in Sarawak: a profile of patients treated in the Sarawak General Hospital.

We performed a cross-sectional study of the demography, clinical and laboratory features of patients with polymyositis and dermatomyositis followed up in our centre from 2006 to 2009. There were 12 cases, with the majority of them (58.3%) being woman. They have a mean age of 57.8 years and mean disease duration of 11.83 (SD 9.92) months. Our patients comprised of multi-ethnic groups with predominantly Chinese (83.3%), Sarawak natives (8.3%) and Malays (8.3%). They have a mean lag time to diagnosis of 3.67 (SD 4.27) months. Nine (75%) patients had dermatomyositis and 3(25%) had polymyositis. The common clinical manifestations found in our patients were proximal myopathy (100%), neck weakness (33.3%), dysphagia (33.3%) and interstitial lung disease (33.3%). For the nine patients with dermatomyositis, the most common dermatological manifestations were shawl sign (88.9%) and V sign (88.9%). Muscle enzymes were raised in 91.7% of patients. Electromyographies were carried out in four patients, and only one of our patients had muscle biopsy. Only 41.7% of our patients have positive ANA. The majority received prednisolone (100%) and hydroxychloroquine (58.3%). Malignancy occurred in five (three nasopharyngeal carcinomas, one sigmoid colon cancer and one lung cancer) out of the nine dermatomyositis patients but none in the polymyositis group. The mortality rate in our group was 4(33.3%) over the 4-year period. This study demonstrated the rarity of PM/DM in our centre with considerable lag time to diagnosis in our patients. Despite lack of muscle biopsy in our centre, our centre achieved appropriate diagnosis and management of PM/DM.

Meta-analysis: the efficacy of anti-viral therapy in prevention of recurrence after curative treatment of chronic hepatitis B-related hepatocellular carcinoma.

BACKGROUND: The role of anti-viral therapy in prevention of hepatocellular carcinoma (HCC) recurrence is to be defined. AIM: To investigate the role of anti-viral therapy in prevention of tumour recurrence after curative treatment of hepatitis B virus (HBV)-related HCC. METHODS: A systematic electronic search on keywords including HCC and different anti-viral therapies was performed through eight electronic databases, including Medline, EMBASE and Cochrane Databases. The primary outcome was HCC recurrence after curative treatment of HBV-related HCC. The secondary outcomes were mortality related to HCC, mortality related to liver failure and the overall mortality. RESULTS: Nine cohort studies were included with a total number of 551 patients: 204 patients with anti-viral treatment group and 347 patients without anti-viral treatment (control group). There was significant difference in the incidence of HCC recurrence in favour of the anti-viral treatment group (55% vs. 58%; odds risk (OR)=0.59, 95% CI 0.35-0.97, P=0.04). The risk of HCC was reduced by 41% in the anti-viral treatment group. There were also significant differences in favour of anti-viral treatment group in terms of liver-related mortality (0% vs. 8%; OR=0.13, 95% CI 0.02-0.69, P=0.02) and overall mortality (38% vs. 42%; OR=0.27, 95% CI 0.14-0.50, P<0.001). CONCLUSIONS: Anti-viral therapy has potential beneficial effects after the curative treatment of HBV-related hepatocellular carcinoma in terms of tumour recurrence, liver-related mortality and overall survival. Anti-viral therapy should be considered after curative treatment of hepatocellular carcinoma.

Systemic lupus erythematosus pregnancies: the Sarawak experience and review of lupus pregnancies in Asia.

We performed a cross-sessional study of all systemic lupus erythematosus (SLE) pregnancies during a 4-year period (2006-2009) to describe the clinical features, maternal and foetal outcomes in our centre. There were 48 pregnancies in 44 women with SLE. Our patients have a mean age of 30.0 years (SD 6.36) and a mean disease duration of 40.67 months (SD 48.23). Our patients have complicated pregnancies: 32.7% have SLE flares, 17.3% have preeclampsia and 48.9% needed caesarean sections. There were 20.0% foetal losses and 17.8% preterm deliveries in our patients. SLE flares contributed to 60.0% of foetal losses in our patients. Lupus pregnancies in our centre generally have a good maternal and foetal outcome comparable to developed countries in Asia. The low incidence of APS, the high usage of hydroxychloroquine and the high SLE remission rate in our patients prior to conceptions contributed to the good outcome.

Ochroconis gallopava peritonitis in a cardiac transplant patient on continuous ambulatory peritoneal dialysis.

Ochroconis gallopava has rarely been isolated in immunosuppressed patients. We report the first case to our knowledge of O. gallopava peritonitis in a cardiac transplant patient on continuous ambulatory peritoneal dialysis. A 58-year-old man who had undergone cardiac transplant 8 years earlier alerted his dialysis nurses to the presence of black material in his catheter lumen. Fungal hyphae were seen on direct microscopy of the black material and from the dialysate effluent, and O. gallopava was cultured from both after 1 day. He was treated successfully with a single dose of intravenous voriconazole, followed by 2 weeks of oral voriconazole.

The many faces of intraosseous haemangioma: a diagnostic headache.

Intraosseous haemangioma constitutes less than ten percent of all primary bone neoplasms. Approximately 75 percent occur in the calvarium or vertebrae, with long bones, short tubular bones and ribs constituting the rest. We describe a 52-year-old woman who presented with left knee pain for 4-5 years and loss of weight over one week. An initial radiograph of the knee showed several well circumscribed isodense lesions with sclerotic rims in the medullary cavity of the distal femur and diaphysis of the left tibia. There were also lucent lesions with a slightly sclerotic rim in the diaphysis of the left tibia and proximal left fibula. In view of the clinical presentation and radiological findings, extensive investigations were made to rule out metastases and multiple myeloma. An open biopsy with segmental osteotomy of the left mid fibular lesion revealed an intraosseous haemangioma.

Systemic sclerosis in Sarawak: a profile of patients treated in the Sarawak General Hospital.

We performed a cross-sectional study of the demography, clinical and laboratory features of patients with systemic sclerosis patients followed up in our centre from 1984 to 2007. There were 23 cases with the majority of them (96%) being female. They have a mean age of 50.3 years and a mean disease duration of 6.02 (SD 5.82) years. Our patients comprised of multi-ethnic groups with predominantly Chinese (52%), Sarawak natives (35%) and Malays (13%). They have a mean lag time to diagnosis of 24.8 (SD 34.8) months. All the patients have sclerodermatous skin changes with 16(70%) having diffuse scleroderma and 7(30%) having limited scleroderma. The common clinical manifestations found in our patients were Raynaud's phenomenon (91%), sclerodactyly (65%), digital ulcers (52%) and pulmonary fibrosis (52%). There was low incidence of pulmonary hypertension (13%) and renal involvement (4%). The majority of our patients (67%) have positive ANA with 33% positive Scl-70. The majority received calcium channel blockers (87%), aspirin (48%) and low-dose prednisolone (48%). One patient developed adenocarcinoma of the lung on follow-up. This study demonstrated the rarity of systemic sclerosis in our centre with considerable lag time to diagnosis in our patients. Diffuse cutaneous systemic scleroderma is more common in our centre with rare pulmonary hypertension and renal involvement.