Length of stay and odds of MRSA acquisition: a dose-response relationship?

The association between methicillin-resistant Staphylococcus aureus (MRSA) colonisation and/or infection with increased morbidity and mortality among hospital patients has long been recognised. We sought to build on previous studies to identify modifiable risk factors associated with the acquisition of MRSA colonisation and infection by conducting a retrospective cohort study on patients admitted through the Emergency Department of an acute tertiary-care general hospital in Singapore which implemented universal on-admission MRSA screening. Patients were assigned to the acquisition or non-acquisition group depending on whether they acquired MRSA during their admission. We used logistic regression models with a patient being in the acquisition group as the binary outcome to identify factors associated with MRSA acquisition. A total of 1302 acquisition and 37 949 non-acquisition group patients were analysed. Fifteen variables were included in the multivariate model. A dose-response relationship between length of stay and odds of MRSA acquisition was observed, with a length of stay 3 weeks or more (Adj OR 11.78-57.36, all P < 0.001) being the single biggest predictor of MRSA acquisition. Other variables significantly associated with MRSA acquisition were: male gender, age 65 or greater, previous MRSA colonisation or infection, exposure to certain antibiotics and surgery, and history of diabetes.

Intranasal octenidine and universal antiseptic bathing reduce methicillin-resistant Staphylococcus aureus (MRSA) prevalence in extended care facilities.

Intranasal octenidine, an antiseptic alternative to mupirocin, can be used for methicillin-resistant Staphylococcus aureus (MRSA) decolonisation in the prevention of nosocomial transmission. A controlled before-after study was conducted in three extended-care hospitals in Singapore. All inpatients with >48 h stay were screened for MRSA colonisation in mid-2015(pre-intervention) and mid-2016(post-intervention). Hospital A: universal daily chlorhexidine bathing throughout 2015 and 2016, with intranasal octenidine for MRSA-colonisers in 2016. Hospital B: universal daily octenidine bathing and intranasal octenidine for MRSA-colonisers in 2016. Hospital C: no intervention. In 2015, MRSA prevalence was similar among the hospitals (Hospital A: 38.5%, Hospital B: 48.1%, Hospital C: 43.4%, P = 0.288). From 2015 to 2016, MRSA prevalence reduced by 58% in Hospital A (Adj OR 0.42, 95% CI 0.20-0.89) and 43% in Hospital B (Adj OR 0.57, 95% CI 0.39-0.84), but remained similar in Hospital C (Adj OR 1.19, 95% CI 0.60-2.33), after adjusting for age, gender, comorbidities, prior MRSA carriage, prior antibiotics exposure and length of hospital stay. Compared with the change in MRSA prevalence from 2015 to 2016 in Hospital C, MRSA prevalence declined substantially in Hospital A (Adj OR 0.35, 95% CI 0.13-0.97) and Hospital B (Adj OR 0.48, 95% CI 0.22-1.03). Topical intranasal octenidine, coupled with universal daily antiseptic bathing, can reduce MRSA colonisation in extended-care facilities.

Reliability and validity of the English and Malay versions of the Driving and Riding Questionnaire: a pilot study amongst older car drivers and motorcycle riders.

OBJECTIVES: This study aimed to examine the reliability and validity of the English and Malay versions of the Driving and Riding Questionnaire. STUDY DESIGN: An observational study with a mix-method approach by utilising both questionnaire and short debriefing interviews. METHODS: Forward and backward translations of the original questionnaire were performed. The translated questionnaire was assessed for clarity by a multidisciplinary research team, translators, and several Malay native speakers. A total of 24 subjects participated in the pilot study. Reliability (Cronbach's alpha) and validity (content validity) of the original and translated questionnaires were examined. RESULTS: The English and Malay versions of the Driving and Riding Questionnaire were found to be reliable tools in measuring driving behaviours amongst older drivers and riders, with Cronbach's alpha of 0.9158 and 0.8919, respectively. For content validity, the questionnaires were critically reviewed in terms of relevance, clarity, simplicity, and ambiguity. The feedback obtained from participants addressed various aspects of the questionnaire related to the improvement of wordings used and inclusion of visual guide to enhance the understanding of the items in the questionnaire. This feedback was incorporated into the final versions of the English and Malay questionnaires. CONCLUSION: The findings of this study demonstrated both the English and Malay versions of the Driving and Riding Questionnaire to be valid and reliable.

Effects of short-term step aerobics exercise on bone metabolism and functional fitness in postmenopausal women with low bone mass.

Measurement of bone turnover markers is an alternative way to determine the effects of exercise on bone health. A 10-week group-based step aerobics exercise significantly improved functional fitness in postmenopausal women with low bone mass, and showed a positive trend in reducing resorption activity via bone turnover markers. INTRODUCTION: The major goal of this study was to determine the effects of short-term group-based step aerobics (GBSA) exercise on the bone metabolism, bone mineral density (BMD), and functional fitness of postmenopausal women (PMW) with low bone mass. METHODS: Forty-eight PMW (aged 58.2 ± 3.5 years) with low bone mass (lumbar spine BMD T-score of -2.00 ± 0.67) were recruited and randomly assigned to an exercise group (EG) or to a control group (CG). Participants from the EG attended a progressive 10-week GBSA exercise at an intensity of 75-85 % of heart rate reserve, 90 min per session, and three sessions per week. Serum bone metabolic markers (C-terminal telopeptide of type 1 collagen [CTX] and osteocalcin), BMD, and functional fitness components were measured before and after the training program. Mixed-models repeated measures method was used to compare differences between the groups (α = 0.05). RESULTS: After the 10-week intervention period, there was no significant exercise program by time interaction for CTX; however, the percent change for CTX was significantly different between the groups (EG = -13.1 ± 24.4 % vs. CG = 11.0 ± 51.5 %, P < 0.05). While there was no significant change of osteocalcin in both groups. As expected, there was no significant change of BMD in both groups. In addition, the functional fitness components in the EG were significantly improved, as demonstrated by substantial enhancement in both lower- and upper-limb muscular strength and cardiovascular endurance (P < 0.05). CONCLUSION: The current short-term GBSA exercise benefited to bone metabolism and general health by significantly reduced bone resorption activity and improved functional fitness in PMW with low bone mass. This suggested GBSA could be adopted as a form of group-based exercise for senior community.

Innovative Patient Safety Curriculum Using iPAD Game (PASSED) Improved Patient Safety Concepts in Undergraduate Medical Students.

INTRODUCTION: While healthcare outcomes have improved significantly, the complex management of diseases in the hospitals has also escalated the risks in patient safety. Therefore, in the process of training medical students to be proficient in medical knowledge and skills, the importance of patient safety cannot be neglected. A new innovation using mobile apps gaming system (PAtient Safety in Surgical EDucation-PASSED) to teach medical students on patient safety was created. Students were taught concepts of patient safety followed by a gaming session using iPad games created by us. This study aims to evaluate the outcome of patient safety perception using the PASSED games created. METHODS: An interactive iPad game focusing on patient safety issues was created by the undergraduate education team in the Department of Surgery, Yong Loo Lin School of Medicine at the National University of Singapore. The game employed the unique touched-screen feature with clinical scenarios extracted from the hospital sentinel events. Some of the questions were time sensitive, with extra bonus marks awarded if the student provided the correct answer within 10 s. Students could reattempt the questions if the initial answer was wrong. However, this entailed demerit points. Third-year medical students posted to the Department of Surgery experienced this gaming system in a cohort of 55-60 students. Baseline understanding of the students on patient safety was evaluated using Attitudes to Patient Safety Questionnaire III (APSQ-III) prior to the game. A 20 min talk on concept of patient safety using the WHO Patient Safety Guidelines was conducted. Following this, students downloaded the apps from ITune store and played with the game for 20-30 min. The session ended with the students completing the postintervention questionnaire. RESULTS: A total of 221 3rd year medical students responded to the survey during the PASSED session. Majority of the students felt that the PASSED game had trained them to understand the processes of medical error (p < 0.001), that their understanding on patient safety issues improved (p = 0.007), and the training prepared them to prevent medical errors (p < 0.001). Many students also recognized the importance of error reporting, where they felt comfortable reporting errors committed by themselves (p < 0.001) or by other people (p < 0.001). They also felt comfortable discussing with the supervisor on medical errors (p < 0.001). Students responded that better teamwork will reduce medical errors (p = 0.003), and teaching teamwork skills will reduce medical errors (p = 0.002). After the PASSED session, students felt that patients could play an important role in preventing medical errors (p < 0.001). They felt that patient safety should be emphasized in undergraduate training (p = 0.024). The level of understanding about concepts of patient safety was also found to improve progressively from the 2nd posting to the 5th posting for both the pre-PASSED and post-PASSED intervention. The pre-PASSED scores for Posting 2 (3.59 ± 1.931), Posting 3 (4.11 ± 1.833), Posting 4 (4.84 ± 1.653), and Posting 5 (4.88 ± 1.642) were significantly higher than the post-PASSED scores for Posting 2 (4.46 ± 2.020), Posting 3 (5.17 ± 1.845), Posting 4 (5.88 ± 1.843), and Posting 5 (5.80 ± 1.843), respectively (p < 0.001). CONCLUSION: Using iPad game (PASSED) to enhance the patient safety teaching has successfully improved the awareness and understanding of patient safety in clinical practice. This training model can be used to teach more senior medical students on the complexity of patient safety issues in medicine.

Neck muscle activity in skydivers during parachute opening shock.

This observational study investigated skydiver neck muscle activity during parachute opening shock (POS), as epidemiological data recently suggested neck pain in skydivers to be related to POS. Twenty experienced skydivers performed two terminal velocity skydives each. Surface electromyography quantified muscle activity bilaterally from the anterior neck, the upper and lower posterior neck, and the upper shoulders; and two triaxial accelerometers sampled deceleration. Muscle activity was normalized as the percentage of reference maximum voluntary electrical activity (% MVE); and temporal muscle activity onset was related to POS onset. Our results showed that neck muscle activity during POS reached mean magnitudes of 53-104% MVE, often exceeding reference activity in the lower posterior neck and upper shoulders. All investigated muscle areas' mean temporal onsets occurred <50 ms after POS onset (9-34 ms latencies), which is consistent with anticipatory motor control. The high muscle activity observed supports that the neck is under substantial strain during POS, while temporal muscle activation suggests anticipatory motor control to be a strategy used by skydivers to protect the cervical spine from POS. This study's findings contribute to understanding the high rates of POS-related neck pain, and further support the need for evaluation of neck pain preventative strategies.

Octenidine exposure was not associated with reduced octenidine susceptibility of meticillin-resistant Staphylococcus aureus in an extended-care facility in Singapore.

OBJECTIVES: Antiseptics such as chlorhexidine gluconate (CHG) and octenidine dihydrochloride (OCT) are frequently used in hospitals to prevent and control the transmission of meticillin-resistant Staphylococcus aureus (MRSA). Given the increasing prevalence of reduced CHG susceptibility of MRSA, there are concerns about the possibility of reduced OCT susceptibility. This study evaluated the prevalence of reduced CHG and OCT susceptibility over 3 years, and assessed the association between OCT exposure and reduced OCT susceptibility in MRSA. METHODS: MRSA isolates from inpatients who acquired MRSA in an extended-care facility between 2019 and 2021 were included in antiseptic susceptibility testing. Inpatients were exposed to universal daily CHG bathing from January to September 2019, and universal daily OCT bathing after October 2019. The minimum inhibitory concentrations (MICs) of CHG and OCT were determined using the broth microdilution method. Multi-variable logistic regression was used to assess if OCT exposure was independently associated with reduced OCT susceptibility. RESULTS: Of 186 isolates, 179 (96%) had reduced CHG susceptibility (MIC ≥4 mg/L) and 46 (25%) had reduced OCT susceptibility (MIC ≥2 mg/L). Reduced OCT susceptibility rates were 26.9%, 13.8% and 14.3% in 2019, 2020 and 2021, respectively. Reduced CHG susceptibility rates were 95.4%, 100% and 95.9% in 2019, 2020 and 2021, respectively. OCT exposure was not associated with reduced OCT susceptibility (adjusted odds ratio 0.23, 95% confidence interval 0.08-0.75; P=0.014), after adjusting for age, gender, race, year of sample collection, days at risk in facility, hospitalization in preceding year, and MRSA colonization/infection in preceding year. CONCLUSION: The prevalence of reduced OCT susceptibility has remained low, despite universal OCT bathing for extended inpatient care. However, the rate of reduced CHG susceptibility was high. OCT exposure was not associated with reduced OCT susceptibility in MRSA.

Bilateral ulna fractures associated with bisphosphonate therapy.

We report a case of bilateral ulna stress fractures following bilateral femoral fractures associated with long-term bisphosphonate use. The patient is an 84-year-old woman receiving 15 years of bisphosphonate therapy. She did not have any preexisting medical conditions which are known secondary causes of bone loss. She was mostly housebound and used a walking frame for ambulation. She presented with atraumatic right ulna pain and subsequent atraumatic left ulna pain a month later. She was treated conservatively in backslabs and her bisphosphonate was stopped. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders.

A novel approach to evaluate the mechanical responses of elastin-like bioresorbable poly(glycolide-co-caprolactone) (PGCL) suture.

Poly(glycolide-co-caprolactone) (PGCL) has become a novice to the bioresorbable suture owing to the synergistic properties taken from the homo-polyglycolide (PGA) and polycaprolactone (PCL) such as excellent bioresorption and flexibility. In addition to under conventional monotonic loading, the understanding of mechanical responses of PGCL copolymers under complex loading conditions such as cyclic and stress relaxation is crucial for its application as a surgical suture. Consequently, the present work focuses on evaluating the mechanical responses of PGCL sutures under monotonic, cyclic, and stress relaxation loading conditions. Under monotonic loading, the stress-strain behavior of the PGCL suture was found to be non-linear with noticeable strain-rate dependence. Under cyclic loading, inelastic responses including stress-softening, hysteresis and permanent set were observed. During cyclic loading, both stress-softening and hysteresis were found to increase with the maximum strain. In multi-step stress relaxation, the PGCL sutures were observed to exhibit a strong viscoelastic response. In an attempt to describe the relationship between the stress-relaxation and strain-induced crystallization (SIC) occurring during the loading and relaxation processes, a schematic illustration of the conformational change of polymer chains in PGCL sutures was proposed in this work. Results showed that SIC was dependent on the strain level as well as the loading and relaxation durations. The inelastic phenomena observed in PGCL sutures can be thus correlated to the combined effect of stress relaxation and SIC.

Effects of eccentric training on hand strength in subjects with lateral epicondylalgia: a randomized-controlled trial.

The main aim of this study was to evaluate the short-term effects of daily eccentric exercises on functional pain-free hand strength in subjects with long-term lateral epicondylalgia. Forty-two subjects with lateral epicondylalgia were randomly assigned either to a 6-week home exercise regimen receiving eccentric training for their wrist extensors and a forearm band or to a control group receiving a forearm band only. The main outcomes were pain-free hand-grip and wrist-extensor strength at mid- and end-intervention follow-ups, 3 and 6 weeks after inclusion, respectively. Secondary outcomes were a change in the proportion of cases with epicondylalgia and ratings of perceived pain (VAS) at follow-up. Thirty-seven (88%) subjects completed both the mid- and the end-intervention follow-up. Exercise members had significantly higher pain-free hand-grip (P=0.025) and wrist-extensor strength (P<0.001) at the end of follow-up, although there was no such effect at mid-intervention. Regression analysis showed a reduction in the proportion of cases in the exercise group at the end of follow-up (P=0.035). However, no between-groups effect emerged for perceived pain. These data suggest that the daily home eccentric exercise regimen is effective in increasing functional pain-free grip strength and reducing cases suffering from lateral epicondylalgia. However, no effect emerged for global perceived pain during the last week.

Carbon-economic inequality in global ICT trade.

The expansion of information and communications technology (ICT) trade has contributed to rising trade imbalances and international tensions. A detailed assessment of the potential carbon and economic impacts of ICT trade is pertinent. We assess to what extent and how the carbon costs and economic benefits embodied in ICT trade were unevenly distributed among global regions in the period 2000-2018 using multiregional input-output models. We show that in 2018, emerging economies received 82% of the CO2 emissions while developed economies gained 42% of the value-added in ICT exports. This carbon-economic inequality (CEI) decreased (i.e., improved) by 16% from 2000 to 2018, arising from global production fragmentation, with developed economies retaining downstream high value-added ICT marketing but outsourcing upper- and middle-stream carbon-intensive material extraction and manufacturing to emerging economies. This study provides insights for enhancing negotiations and cooperation among global regions to light a path toward sustainable ICT trade.

Mechanical Response of Glass-Epoxy Composites with Graphene Oxide Nanoparticles.

Graphene-based fillers possess exceptional properties that encourage researchers toward their incorporation in glass-epoxy (GE) polymer composites. Regarding the mechanical and wear properties of glass-epoxy composites, the effect of graphene oxide (GO) reinforced in glass-epoxy was examined. A decrease in tensile modulus and increase in tensile strength was reported for 1 wt. % of GO. A shift in glass transition temperature Tg was observed with the addition of GO. The cross-link density and storage modulus of the composite decreased with the addition of GO. The decrease in dissipation energy and wear rate was reported with the increase in GO concentration. A simple one-dimensional damage model of nonlinear nature was developed to capture the stress-strain behavior of the unfilled and filled glass-epoxy composite. Tensile modulus E, Weibull scale parameter σo, and Weibull shape parameter ß were considered to develop the model. Finally, to understand the failure mechanisms in GO-filled composites, a scanning electron microscopic (SEM) examination was carried out for tensile fractured composites.

First nosocomial cluster of COVID-19 due to the Delta variant in a major acute care hospital in Singapore: investigations and outbreak response.

OBJECTIVES: The first large nosocomial cluster of coronavirus disease 2019 (COVID-19) in Singapore in April 2021 led to partial closure of a major acute care hospital. This study examined factors associated with infection among patients, staff and visitors; investigated the possible role of aerosol-based transmission; evaluated the effectiveness of BNT162.b2 and mRNA1273 vaccines; and described the successful containment of the cluster. METHODS: Close contacts of patients with COVID-19 and the affected ward were identified and underwent surveillance for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Patient, staff and visitor cohorts were constructed and factors associated with infection were evaluated. Phylogenetic analysis of patient samples was performed. Ward air exhaust filters were tested for SARS-CoV-2. RESULTS: In total, there were 47 cases, comprising 29 patients, nine staff, six visitors and three household contacts. All infections were of the Delta variant. Ventilation studies showed turbulent air flow and swabs from air exhaust filters were positive for SARS-CoV-2. Vaccine breakthrough infections were seen in both patients and staff. Among patients, vaccination was associated with a 79% lower odds of infection with COVID-19 (adjusted odds ratio 0.21, 95% confidence interval 0.05-0.95). CONCLUSIONS: This cluster occurred despite enhancement of infection control measures that the hospital had undertaken at the onset of the COVID-19 pandemic. It was brought under control rapidly through case isolation, extensive contact tracing and quarantine measures, and led to enhanced use of hospital personal protective equipment, introduction of routine rostered testing of inpatients and staff, and changes in hospital infrastructure to improve ventilation within general wards.

Routine antiseptic baths and MRSA decolonization: diverse approaches across Singapore's acute-care hospitals.

To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in 'bioburden reduction' rather than longer-term clearance.

Monitoring of intra-operative nociception: skin conductance and surgical stress index versus stress hormone plasma levels.

'Surgical Stress Index' and the 'Number of Fluctuations in Skin Conductance.s⁻¹, use different methods to analyse sympathetic tone and so provide an estimate of peri-operative analgesia. The aim of our study was to investigate the relationship between these methods and stress hormone plasma levels. In 20 patients scheduled for elective surgery, values of the two methods, mean arterial blood pressure, heart rate and blood samples (to measure plasma levels of adrenaline, noradrenaline, adrenocorticotrophic hormone and cortisol) were obtained at five time points. Changes in Surgical Stress Index and the Number of Fluctuations in Skin Conductance.s⁻¹ only partially reflected changes in plasma noradrenaline levels. Surgical Stress Index, heart rate and blood pressure, but not the 'Number of Fluctuations in Skin Conductance.s⁻¹ changed in response to changes in depth of analgesia by showing significant differences between before and after a bolus of fentanyl. However, the overall predictive ability of both methods was poor.

Ankle-joint mobility and standing squat posture in elite junior cross-country skiers. A pilot study.

AIM: Skating technique in cross-country skiing is a complex multi-joint movement with kinematics comparable to those of the standing squat exercise where any restricted joint mobility in the lower extremity-chain may change the movement pattern. The aim of this pilot study was to investigate the effect of ankle mobility on trunk posture during squat exercise in cross-country skiers. METHODS: Seven elite junior cross-country skiers (age range 17-19 years) performed two different standing squats, one with hands on hips and one with arms extended above the head. The squats were recorded on video and analyzed in selected positions: 90 degrees and maximal knee flexion. Segment angles for shank and trunk were calculated from anatomical references relative to vertical/horizontal orientation in space. Recordings from passive ankle dorsiflexion were correlated with 1) trunk flexion, and 2) angle index (trunk flexion relative to shank angle). RESULTS: Reduced ankle dorsiflexion was moderately associated with increased trunk flexion with hands on hips (r=-0.51 to -0.57), and arms above head (r=-0.61 to -0.64). Further, reduced dorsiflexion was also moderately associated with decreased angle index with hands on hip (r=0.60 to 0.67) but highly associated with decreased angle index with arms above head (r=0.75 to 0.76). CONCLUSION: The results imply that reduced ankle dorsal mobility is related to decreased angle index as well as increased trunk flexion during squat exercise, thus indicating the relevance of good ankle joint mobility for appropriate upper-body posture during squat exercise.

Intranasal octenidine and universal chlorhexidine bathing can reduce meticillin-resistant Staphylococcus aureus acquisition in an extended care facility in Singapore.

Meticillin-resistant Staphylococcus aureus (MRSA) is prevalent in extended care facilities. We conducted a quasi-experimental before-after study in a 100-bed rehabilitation hospital, from January 2013 to June 2019. Universal chlorhexidine bathing was implemented throughout the period, with intranasal octenidine for MRSA colonizers added from September 2017. Interrupted time-series with segmented regression analysis revealed that after adjusting for at-admission MRSA colonization and hand hygiene compliance, a constant trend was observed pre implementation of intranasal octenidine (adjusted mean coefficient: 0.012; 95% confidence interval: -0.037 to 0.06), with an immediate decrease with implementation (-2.145; -0.248 to -0.002; P = 0.033), followed by a significant reduction in MRSA acquisition post implementation (-0.125; -0.248 to -0.002; P = 0.047).

Neuroimaging in Zoonotic Outbreaks Affecting the Central Nervous System: Are We Fighting the Last War?

When preparing for the coronavirus disease 2019 pandemic and its effects on the CNS, radiologists should be familiar with neuroimaging appearances in past zoonotic infectious disease outbreaks. Organisms that have crossed the species barrier from animals to humans include viruses such as Hendra, Nipah, Severe Acute Respiratory Syndrome, and influenza, as well as bacteria and others. Brain CT and MR imaging findings have included cortical abnormalities, microinfarction in the white matter, large-vessel occlusion, and features of meningitis. In particular, the high sensitivity of diffusion-weighted MR imaging in detecting intracranial abnormalities has been helpful in outbreaks. Although the coronaviruses causing the previous Severe Acute Respiratory Syndrome outbreak and the current coronavirus disease 19 pandemic are related, it is important to be aware of their similarities as well as potential differences. This review describes the neuroimaging appearances of selected zoonotic outbreaks so that neuroradiologists can better understand the current pandemic and potential future outbreaks.