Small bowel obstruction secondary to crab shell bezoar: A case report.

Small bowel obstruction is a common surgical condition that needs surgical intervention if conservative measures fail. Bezoar is a rare aetiology of small bowel obstruction with incidence of 4.5%. The bezoars can be grouped, according to the content, into four common types: phytobezoars, trichobezoars, pharmacobezoars, and lactobezoars. However, unusual bezoars like plastic bezoars and metal bezoars have been reported too. Herein, we report a case of an elderly lady who was treated for small bowel obstruction due to crab shell bezoar. This is the first case reported in literature. Ingestion of large intact pieces of crab shell should be avoided due to the potential of causing small bowel obstruction.

Clinical and economic impact of school-based nonavalent human papillomavirus vaccine on women in Singapore: a transmission dynamic mathematical model analysis.

OBJECTIVE: To examine the epidemiological and economic impact of a nine-valent (nonavalent) human papillomavirus (HPV) 6/11/16/18/31/33/45/52/58 vaccine programme for young teenagers in Singapore. DESIGN: Mathematical modelling. SETTING: Pharmaco-economic simulation projection. POPULATION: Singapore demography. METHODS: Clinical, epidemiological and financial data from Singapore were used in a validated HPV transmission dynamic mathematical model to analyse the impact of nonavalent HPV vaccination over quadrivalent and bivalent vaccines in a school-based 2-dose vaccination for 11- to 12-year-old girls in the country. The model assumed routine cytology screening in the current rate (50%) and vaccine coverage rate of 80%. MAIN OUTCOME MEASURES: Changes over a 100-year time period in the incidence and mortality rates of cervical cancer, case load of genital warts, and incremental cost-effectiveness ratio (ICER). RESULTS: Compared with bivalent and quadrivalent HPV vaccination programmes, nonavalent HPV universal vaccination resulted in an additional reduction of HPV31/33/45/52/58 related CIN1 of 40.5%, CIN 2/3 of 35.4%, cervical cancer of 23.5%, and cervical cancer mortality of 20.2%. Compared with bivalent HPV vaccination, there was an additional reduction in HPV-6/11 related CIN1 of 75.7%, and genital warts of 78.9% in women and 73.4% in men. Over the 100 years, after applying a discount of 3%, disease management cost will be reduced by 32.5% (versus bivalent) and 7.5% (versus quadrivalent). The incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year gained was SGD 929 compared with bivalent vaccination and SGD 9864 compared with quadrivalent vaccination. CONCLUSION: Universal two-dose nonavalent HPV vaccination for 11- to 12-year-old adolescent women is very cost-effective in Singapore. TWEETABLE ABSTRACT: Nonavalent HPV vaccination of 11- to 12-year-old girls is cost-effective in Singapore.

Risk assessment and laboratory investigation of respiratory illness in travellers returning to Singapore 2012-2015: experience from the MERS-CoV Surveillance Programme.

Since the emergence of Middle East respiratory syndrome coronavirus (MERS-CoV), Singapore has enhanced its national surveillance system to detect the potential importation of this novel pathogen. Using the guidelines from the Singapore Ministry of Health, a suspect case was defined as a person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness, and with an epidemiological link to countries where MERS-CoV cases had been reported within the preceding 14 days. This report describes a retrospective review of 851 suspected MERS-CoV cases assessed at the adult tertiary-care hospital in Singapore between September 2012 and December 2015. In total, 262 patients (31%) were hospitalized. All had MERS-CoV infection ruled out by RT-PCR or clinical assessment. Two hundred and thirty (88%) of the hospitalized patients were also investigated for influenza virus by RT-PCR. Of these, 62 (27%) tested positive for seasonal influenza. None of the patients with positive influenza results had been vaccinated in the year prior to hospital admission. Ninety-three (36%) out of the 262 hospitalized patients had clinical and/or radiological evidence of pneumonia. This study demonstrates the potential benefits of pre-travel vaccination against influenza and pneumococcal disease.

Kinematic analysis of the scaphoid using gated four-dimensional CT.

AIM: To investigate the kinematics of the scaphoid while the wrist was in radioulnar motion using gated four-dimensional computed tomography (4DCT) imaging. MATERIALS AND METHODS: Six cadaveric wrist specimens were scanned in the following order of capsulotomy and ligament sectioning: (1) ligaments intact, (2) capsulotomy, (3) scapholunate ligament division, and lastly, (4) lunotriquetral ligament division. A three-dimensional model was then reconstructed to analyse the translation and angular displacements of the scaphoid. RESULTS: The magnitude of displacement was found to increase with each consecutive ligament sectioning. Translation along the y-axis was statistically significant, with the scaphoid shifting up to 1.39 mm from its original position after complete sectioning of the ligaments while the wrist was deviating radially. Angular displacement about all three axes was statistically significant, with the highest occurring in the flexion-extension plane when the scaphoid flexed by 9.1° from its original position after total sectioning of the ligaments. CONCLUSION: The present study showed that changes in the kinematics of the scaphoid can be detected using 4DCT, thus demonstrating its feasibility in the diagnosis of dynamic carpal instability, which only presents during motion.

Active disease is independently associated with more severe anxiety rather than depressive symptoms in patients with systemic lupus erythematosus.

OBJECTIVE: The inter-correlation between and co-existence of depression and anxiety may engender inconsistency in addressing the relationship between the severity of depression and disease activity of systemic lupus erythematosus (SLE). We aimed at identifying whether lupus disease activity is independently associated with depression and anxiety in lupus patients. METHODS: Adult lupus patients were assessed for the severity of depressive and anxiety symptoms and lupus disease activity by using the Hospital Anxiety and Depression Scale (HADS) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), respectively. Age- and gender-matched healthy controls (HCs) were recruited for comparison. Prevalence and severity of depressive and anxiety symptoms were compared between lupus patients and HCs. Independent relationships between the severity of anxiety (HADS-Anxiety) and depressive (HADS-Depression) symptoms, and SLEDAI were studied with regression models. RESULTS: In total, 110 lupus patients and 110 HCs were studied. Lupus patients had significantly higher HADS scores than HCs (10.82 ± 6.5 vs. 7.34 ± 4.9, p < 0.001). Significantly more lupus patients had anxiety (40.9 vs. 21.8%, p = 0.002) and depressive symptoms (15.5 vs. 6.4%, p = 0.025) than HCs. Multiple linear regression analyses revealed that SLEDAI (ß = 0.160, p = 0.016), calcineurin inhibitor non-use (ß = -1.929, p = 0.041) and past cyclophosphamide non-use (ß = -1.603, p = 0.039) independently predicted HADS-Anxiety amongst lupus patients even after adjusting for HADS-Depression. Conversely, SLEDAI (ß = 0.014, p = 0.834) lost its significant univariate correlation with HADS-Depression after controlling for HADS-Anxiety and other covariates. CONCLUSION: Anxiety is more common in lupus patients than in HCs, and its severity is independently associated with more active SLE regardless of the presence or absence of concomitant depression.

Effect of the structure on luminescent characteristics of SRO-based light emitting capacitors.

In this paper, we study the structural, optical and electro-optical properties of silicon rich oxide (SRO) films, with 6.2 (SRO30) and 7.3 at.% (SRO20) of silicon excess thermally annealed at different temperatures and used as an active layer in light emitting capacitors (LECs). A typical photoluminescence (PL) red-shift is observed as the silicon content and annealing temperature are increased. Nevertheless, when SRO30 films are used in LECs, a resistance switching (RS) behavior from a high current state (HCS) to a low conduction state (LCS) is observed, enhancing the intense blue electroluminescence (EL). This RS produces a long spectral blue-shift (∼227 nm) between the EL and PL band, and it is related to structural defects created by a high current flow through preferential conductive paths breaking off Si-Si bonds from very small silicon nanoparticles (Si-nps) (Eδ (Si ↑ Si ≡ Si) centers). LECs with SRO20 films do not present the RS behavior and only exhibit a slight shift between PL and EL, both in red spectra. The carrier transport in these LEC devices is analyzed as being trap assisted tunnelling and Poole-Frenkel through a quasi 'continuum' of defect traps and quantum dots for the conduction mechanism in SRO30 and SRO20 films, respectively. The results prove the feasibility of obtaining light emitting devices by using simple panel structures with Si-nps embedded in the dielectric layer.

Identification of rickettsiae from wild rats and cat fleas in Malaysia.

Rickettsioses are emerging zoonotic diseases reported worldwide. In spite of the serological evidence of spotted fever group rickettsioses in febrile patients in Malaysia, limited studies have been conducted to identify the animal reservoirs and vectors of rickettsioses. This study investigated the presence of rickettsiae in the tissue homogenates of 95 wild rats and 589 animal ectoparasites. Using PCR assays targeting the citrate synthase gene (gltA), rickettsial DNA was detected in the tissue homogenates of 13 (13.7%) wild rats. Sequence analysis of the gltA amplicons showed 98.6-100% similarity with those of Rickettsia honei/R. conorii/R. raoultii (Rickettsiales: Rickettsiaceae). Sequence analysis of outer membrane protein A gene (ompA) identified Rickettsia sp. TCM1 strain from two rats. No rickettsia was detected from Laelaps mites, Rhipicephalus sanguineus and Haemaphysalis bispinosa ticks, and Felicola subrostratus lice in this study. R. felis was identified from 32.2% of 177 Ctenocephalides felis fleas. Sequence analysis of the gltA amplicons revealed two genotypes of R. felis (Rf31 and RF2125) in the fleas. As wild rats and cat fleas play an important role in the enzoonotic maintenance of rickettsiae, control of rodent and flea populations may be able to reduce transmission of rickettsioses in the local setting.

The inhibitory effects of aureobasidin A on Candida planktonic and biofilm cells.

Aureobasidin A (AbA) is a cyclic depsipeptide antifungal compound that inhibits a wide range of pathogenic fungi. In this study, the in vitro susceptibility of 92 clinical isolates of various Candida species against AbA was assessed by determining the planktonic and biofilm MICs of the isolates. The MIC(50) and MIC(90) of the planktonic Candida yeast were 1 and 1 µg ml(-1), respectively, whereas the biofilm MIC(50) and MIC(90) of the isolates were 8 and ≥64 µg ml(-1) respectively. This study demonstrates AbA inhibition on filamentation and biofilm development of C. albicans. The production of short hyphae and a lack of filamentation might have impaired biofilm development of AbA-treated cells. The AbA resistance of mature Candidia biofilms (24 h adherent population) was demonstrated in this study.

Prevalence of plasmid-mediated qnr determinants and gyrase alteration in Klebsiella pneumoniae isolated from a university teaching hospital in Malaysia.

BACKGROUND AND OBJECTIVES: The ciprofloxacin resistance of Klebsiella (K.) pneumoniae is mediated primarily through alterations in type II topoisomerase (gyrA) gene and plasmid-mediated quinolone resistance-conferring genes (qnr). This study aimed to define the prevalence of plasmid-mediated quinolone resistance-conferring genes (qnr) and type II topoisomerase (gyrA) alterations of a population of ciprofloxacin-resistant (n = 21), intermediate (n = 8), and sensitive (n = 18) K. pneumoniae isolates obtained from a teaching hospital at Kuala Lumpur, Malaysia. MATERIALS AND METHODS: A multiplex PCR assay was performed for simultaneous detection of qnrA, qnrB and qnrS. Sequence analysis of the amplified gyrA and gyrB regions of the isolates were performed. RESULTS: The findings in this study revealed the emergence of a high prevalence (48.9%) of qnr determinants in our isolates. Four variants of plasmid-mediated qnr determinants (qnrB1, qnrB6, qnrB10 and qnrS1) were detected from 11 (52.4%) ciprofloxacin-resistant, 5 (62.5%) intermediate and 7 (38.9%) sensitive isolates. gyrA alterations were detected from 18 (85.7%) ciprofloxacin-resistant isolates. Single gyrA alterations, Ser83→Tyr, Ser83→Ile, and Asp87→Gly, and double alterations, Ser83→Phe plus Asp87→Ala and Ser83→Tyr plus Asp87→Asn were detected. While ciprofloxacin resistance was significantly associated with gyrA alteration (Ser83, p = 0.003; Asp87, p = 0.005; double alteration, p = 0.016), no significant association of ciprofloxacin resistance was noted with the presence of qnr determinants (p = 0.283). CONCLUSIONS: The findings in this study demonstrate the emergence of qnr determinants and gyrA alterations contributed to the development and spread of fluoroquinolone resistance in the Malaysian isolates.

Infant responsiveness, alertness, haemoglobin and growth in rural Sidama, Ethiopia.

Several recent studies have supported relations between infant behaviour (alertness and responsiveness) and nutrition in addition to investigating infant behaviour within the context of changes in iron status over time. Existing research is typically limited to the investigation of the effects of a single vitamin or mineral, and no studies have been found that examined the influence that early alertness and responsiveness have on growth in early infancy, despite the fact that relations between behaviour and nutritional status may be bidirectional. The current study used a sample of Ethiopian infants and investigated anthropometrics, haemoglobin, the frequency of alertness and the frequency of responsiveness at 6 and 9 months of age. Six-month weight-for-age predicted 9-month frequency of alertness, while 6-month haemoglobin predicted 9-month frequency of responsiveness. Compared with responsive infants, non-responsive infants at 6 months remained more non-responsive at 9 months, although weight-for-age for both groups converged at 9 months. Results support relations between nutrition and behaviour (alertness and responsiveness) and provide evidence of a potentially useful tool (the Laboratory Temperament Assessment Battery) that was adapted to evaluate these relations in Ethiopia.

The pathology of 'scale drop syndrome' in Asian seabass, Lates calcarifer Bloch, a first description.

This is the first pathological description of 'scale drop syndrome' (SDS) in Asian seabass, Lates calcarifer Bloch. Cumulative mortality was estimated at 40-50%. The vasculitis in all major organs including the skin and associated tissue necrosis was distinctive. The dermis overlying scale beds was often necrotic and associated with scale loss. Necrosis of splenic ellipsoids, renal glomeruli and choroid rete glands of eye were further hallmarks of a disease with systemic vascular involvement. The brain was not spared vascular damage, and the resulting multifocal encephalomalacia probably accounts for the spiral swimming behaviour in some affected fish. Other lesions included accentuated hepatic lobulation and gastric gland necrosis. Nuclear chromatin margination and karyolysis in hepatocytes, renal tubular epithelium and gastric and intestinal epithelium suggest specific targeting of cells. Basophilic cytoplasmic inclusions were present in spleen, kidney, liver, heart and choroid rete, but they were not prominent. Using transmission electron microscopy, two morphological forms of virions were observed: single- and double-enveloped hexagonal virions. Based on size and morphology, these virions resemble iridovirus or herpesvirus. The cause of SDS is unknown, but the pathological changes, especially the vasculitis, suggest an infectious aetiology, possibly viral.

Interfragmentary compression profile of 4 headless bone screws: an analysis of the compression lost on reinsertion.

PURPOSE: To evaluate the interfragmentary compression force generated by 4 different types of headless compression screws and to examine the effects of removal and reinsertion of the screw. METHODS: We chose foot bones rather than scaphoids for the model because they were larger and would enable comparison of 2 screw designs in the same bone, thereby controlling for the effect of interspecimen variability. A transverse osteotomy was made in 10 fresh-frozen cadaveric navicular bones and 10 medial cuneiforms. A load cell was used to measure compression between the 2 fragments as a screw was inserted across the fracture. Each bone was tested twice, with an Acutrak Mini (Acumed, Hillsboro, OR; n = 10) and an SBi AutoFIX screw (SBi, Morrisville, PA; n = 10) or an Extremifix (Osteomed, Addison, TX; n = 10) and a Barouk screw (Depuy, Warsaw, IN; n = 10). Compression was recorded at initial insertion and on removal and reinsertion of the screw twice to the same position. Compression was also measured after one additional full turn further than the initial position. RESULTS: The mean interfragmentary compression generated by the Acutrak Mini screw was greater than that of the SBi AutoFIX screw (96 N vs 22 N). There was a trend toward a greater mean compression generated by the Extremifix screw compared to the Barouk screw (85 N vs 22 N). There was a significant loss of compression upon removal and reinsertion of the screws. An additional full turn of the screw was able to re-establish a large proportion of the original compression. CONCLUSIONS: The compression forces achieved by headless screw systems appeared to vary according to the screw design, depth of insertion, and the quality of the bone. Substantial compression was lost if the screw was removed and replaced. Some screw designs appeared to require a greater depth of insertion to achieve effective compression, and the number of additional turns required to re-establish compression might vary according to the thread design. CLINICAL RELEVANCE: Surgeons should be aware of the compression profile of each screw design and the effect of screw removal and reinsertion in the clinical setting of small bone fixation.

Interactive relations among maternal depressive symptomatology, nutrition, and parenting.

Theoretical models linking maternal nutrition, depressive symptomatology, and parenting are underdeveloped. However, existing literature suggests that iron status and depressive symptomatology interact in relation to problematic parenting styles (authoritarian, permissive). Therefore, in the current study the authors investigate these interactive relations in a sample of breastfeeding mothers (n = 105) interviewed at three months postpartum. Participants completed questionnaires (from December 2008 to January 2011) regarding their depressive symptomatology and parenting styles. Iron status (i.e., hemoglobin, soluble transferrin receptors, and serum ferritin concentrations) was assessed from blood samples. Significant interactions were found between iron status and depressive symptomatology in relation to authoritarian parenting style (low warmth, high punishment and directiveness). For those women with hemoglobin below 14.00 g/dL, depressive symptomatology was positively related to authoritarian parenting style (p < 0.001). Thus, screening for poor iron status and depressive sympatomology in postpartum women may help to identify those at risk for problematic parenting. Dietary interventions may help to eliminate relations between depressive symptoms and problematic parenting.

Serological review of Bartonella henselae and Bartonella quintana infection among Malaysian patients with unknown causes of febrile illnesses.

Limited information is available on human exposure to Bartonella infection, i.e., Bartonella henselae (causative agent of cat scratch disease) and Bartonella quintana (causative agent of trench fever) in West Malaysia. This study reports a review of serological findings obtained from patients attending to a teaching hospital in Klang Valley, Malaysia. An indirect immunofluorescence assay (IFA) was used to determine IgG and IgM antibody titers against B. henselae and B. quintana. In a pilot study conducted between 2013-2015, IgG antibodies against Bartonella spp. (either B. quintana and B. henselae) were detected in 14 (36.8%) of 38 patients who were clinically suspected of rickettsial infections, while IgM antibody was detected in 4 (10.5%) patients. This has prompted us to investigate the serologic responses of patients who were clinically suspected of other febrile causes besides rickettsial infection. Of the 59 serum samples analysed in a follow-up investigation, Bartonella IgG antibodies were detected from 7 (11.9%) patients, of which 5 (27.8%) and 2 (18.2%) patients were clinically suspected of rickettsial infection (n=18) and dengue (n=11), respectively. None of the sera obtained from the leptospirosis (n=10), legionellosis (n=10) and mycoplasma infection (n=10) groups were seropositive to Bartonella spp. The review of Bartonella serological findings in this study highlights that Bartonella infection is not uncommon and should be considered as one of the causes for febrile illness in Malaysia.

Imported case ofLeishmania tropica cutaneous leishmaniasis in a 10-year-old child in Malaysia.

The present paper reported a first imported case of cutaneous leishmaniasis in a 10-year- old child who returned from Saudi Arabia to Malaysia. Six weeks after his travel to Malaysia, two erythematous dermal nodules were developed over his right cheek and chin. Occurrence of intracellular amastigote of Leishmania was observed through examination of skin biopsy with hematoxylin and eosin stain. Furthermore, molecular analysis of ribosomal internal transcribed spacer 1 (ITS1) of Leishmania spp. confirmed the child was infected with Leishmania tropica. The child was given oral fluconazole and he had a 80% recovery before he went back to Saudi Arabia.

Surgical site infection and development of antimicrobial sutures: a review.

Sutures are used to facilitate wound healing and play an important role in ensuring the success of surgical interventions in healthcare facilities. Suture-associated surgical site infection (SSI) may develop when bacterial contaminants colonize the suture surface and establish biofilms that are highly resistant to antibiotic treatment. The outcome of SSI affects postoperative care, leading to high rates of morbidity and mortality, prolonged hospitalization, and increased financial burden. Antimicrobial sutures coated with antiseptics such as triclosan and chlorhexidine have been used to minimize the occurrence of SSI. However, as the efficacy of antiseptic-based sutures may be affected due to the emergence of resistant strains, new approaches for the development of alternative antimicrobial sutures are necessary. This review provides an update and outlook of various approaches in the design and development of antimicrobial sutures. Attaining a zero SSI rate will be possible with the advancement in suturing technology and implementation of good infection control practice in clinical settings.

A quality improvement study: Optimizing pneumococcal vaccination rates in children with cochlear implants.

Children with cochlear implants are at increased risk of invasive pneumococcal disease, with national and international guidelines recommending additional pneumococcal vaccines for these children. This study aimed to examine the pneumococcal immunization status and rate of invasive pneumococcal disease in children with cochlear implants at a tertiary paediatric hospital over a 12-year period. Additionally, the impacts of vaccination reminders and a dedicated immunization clinic on pneumococcal vaccination rates were assessed. This quality improvement study included 200 children who had received a cochlear implant through the Children's Hearing Implant Program at a tertiary paediatric hospital servicing the state of Western Australia. The majority of children (88%) were not up to date with additionally recommended pneumococcal vaccinations. Over the 12-year study period, 2% of children developed invasive pneumococcal disease associated with cochlear implant infections. Generic and personalized electronic immunization reminders improved pneumococcal vaccine up-take in this paediatric cochlear implant setting from 12% (19/153) at baseline to 49% (75/153, p < 0.0001) post implementation. The value of a nurse-led dedicated immunization clinic was also demonstrated with all children (42/42, 100%) up to date with Prevenar13 and the majority (34/42, 81%) up to date with Pneumovax23 post initiation of this referral pathway. These data support the expansion of this model to other medically-at-risk paediatric groups that have been highlighted consistently to be under-vaccinated.

Parenting styles, parental response to child emotion, and family emotional responsiveness are related to child emotional eating.

The aim of the present study was to examine the relations of parenting style, parent response to negative child emotion, and family emotional expressiveness and support to child emotional eating. Mothers (N=450) completed questionnaires and their 6-8-year-old children (N=450) were interviewed. Results showed that emotional eating was negatively predicted by authoritative parenting style and family open expression of affection and emotion, and positively predicted by parent minimizing response to child negative emotion. Results suggest the need for early prevention/intervention efforts directed to these parenting and family variables.

Alternating hemiplegia of childhood: successful treatment with topiramate and flunarizine, a case report.

Alternating hemiplegia of childhood (AHC) is a rare neurological disorder which usually presents before 18 months of age and is characterised by recurrent alternating episodes of hemiparesis. A single effective treatment for this condition is yet to be established; flunarizine is currently the most widely used but with varying degrees of success. An 18-month-old child presented with AHC and treatment with a combination of topiramate and flunarizine made a significant difference in controlling the frequency and severity of the attacks. This possibly allowed a better developmental outcome than in most children with this condition. Topiramate combined with flunarizine for treating AHC has much potential for further research.