Attitudes and perception of influenza vaccines among older people in Singapore: A qualitative study.

BACKGROUND: Despite recommendations for influenza vaccination of people aged 65 and above, uptake rate of influenza vaccines remains low. This study aims to understand barriers and motivators behind older adult's decision on influenza vaccination. METHODS: Face to face interviews with participants aged 65 and above were conducted and audio recorded in Geylang polyclinic in Singapore. Thematic content analysis was used to organise the data. RESULTS: 15 older adults were interviewed, aged between 66 and 85 years old. 6 were vaccine refusers, 3 defaulters and 6 acceptors. A perceived lack of vulnerability, fear of side effects, and trivialisation of influenza were common reasons for not taking the vaccine. Encouragement from family and friends, travel and previous positive vaccination experiences were motivators for getting vaccinated. Healthcare workers played a role in influencing many of the participants' decision-making. Common misconceptions included vaccines considered as necessary only before travel and as a cure rather than prevention. Most participants exhibited ambivalence, giving reasons both for and against vaccine uptake. DISCUSSION: Most older adults do not perceive influenza as a potentially serious disease nor trust in influenza vaccines' efficacy. Misconceptions played a significant role in vaccine decline. Novel findings include the importance of the family unit in decision making, prioritization of chronic health problems over vaccination and misconception that vaccines are only needed when travelling out of country. Healthcare workers and family members appear to be important influencers in the decision making of older adults and should be actively engaged in future health promotion initiatives.

First detection of the mcr-1 colistin resistance gene in Escherichia coli from a patient with urinary tract infection in Myanmar.

Colistin-resistance gene mcr-1 was detected in an Escherichia coli sample among 442 clinical isolates collected in a tertiary-care hospital in Yangon, Myanmar, in 2018. This isolate was classified into phylogroup A-ST23 complex and harboured bla CTX-M-15 and bla TEM-1, associated with multiple mutations in quinolone-resistance-determining regions in gyrA and parC.

'It's effective but should I bother?' A study of personal protection measures against Malaria in urban India.

OBJECTIVES: Malaria affects millions of people in urban and rural India every year. This study addresses two main gaps in current research: 1) attitudes towards personal protective strategies against Malaria among urban populations; and 2) understanding of the extent to which urban health information seeking preferences shape preventive behaviours. STUDY DESIGN: Cross-sectional face-to-face surveys using stratified sampling design. METHODS: A 60-min survey was carried out to 1000 middle-of-pyramid (MOP) population in five main cities in India by trained interviewers. Variables assessed included perceived effectiveness and actual practice of 14 scientific and indigenous personal protection methods, Malaria-related attitudes (susceptibility, severity and response efficacy) and health information seeking preferences. RESULTS: Actual practice of Malaria preventive behaviours was found to be significantly lower than the perceived effectiveness of each of the fourteen scientific and indigenous methods. Television, newspapers, and mobile phones were reported as the top three preferred media for seeking public health information. Lastly, perceived susceptibility, response efficacy, and health-related media use were found to play significant roles in predicting actual practice behaviours. CONCLUSIONS: Our study highlights a need for health authorities to focus on translating positive attitudes to actual practice of preventive behaviours. Communication efforts may focus on the use of TV, newspapers and mobile phones for greater reach and efficacy. Other implications for Malaria prevention programs are discussed.

Experience of first- and subsequent-line systemic therapy in the treatment of non-small cell lung cancer.

INTRODUCTION: The treatment of advanced non-small cell cancer (NSCLC) has changed with multiple new treatment algorithms proposed based on histological and molecular subtyping but low mutation rates will ensure the dominance of cytotoxic chemotherapy. Accordingly, we undertook a detailed review of our practice delivering multiple lines of systemic therapy. METHOD: We undertook a retrospective review of consecutive patients presenting with advanced (stage IIIb/IV) NSCLC treated with systemic therapy at two UK hospitals during a 2-year period, January 2007 to December 2008. RESULTS: A total of 130 patients were identified, treated with predominantly carboplatin/gemcitabine (20 initially radically). Fifty of 110 patients (45%) treated with first-line systemic therapy subsequently received second-line therapy, of which 10 patients received third-line and two patients fourth-line therapy. Sixty three of 110 first-line patients (58%) achieved clinical benefit, 19 out of 50 (38%) in the second-line, 6 out of 10 (60%) in third-line but both patients progressed at fourth-line. Median overall survival for 110 patients was 10 months (95% confidence interval [CI] 8.6-11.4); but 16 months (95% CI 14-17.9) in those receiving multiple lines. Median survival from the first cycle of last-line treatment to death in the multiple therapy lines was 5 months (95% CI 2.6-7.3) and the majority of patients spent more time off treatment. CONCLUSION: Overall our outcomes are consistent with published data and show good survival times can be achieved. The future of advanced NSCLC is in selecting the best treatment approach on a histological and genotypic basis.

Foxo1, a novel regulator of osteoblast differentiation and skeletogenesis.

Skeletogenesis depends on the activity of bone-forming cells derived from mesenchymal cells. The pathways that control mesenchymal cell differentiation are not well understood. We propose that Foxo1 is an early molecular regulator during mesenchymal cell differentiation into osteoblasts. In mouse embryos, Foxo1 expression is higher in skeletal tissues, while Foxo1 silencing has a drastic impact on skeletogenesis and craniofacial development, specially affecting pre-maxilla, nasal bone, mandible, tibia, and clavicle. Similarly, Foxo1 activity and expression increase in mouse mesenchymal cells under the influence of osteogenic stimulants. In addition, silencing Foxo1 blocks the expression of osteogenic markers such as Runx2, alkaline phosphatase, and osteocalcin and results in decreased culture calcification even in the presence of strong osteogenic stimulants. Conversely, the expression of these markers increases significantly in response to Foxo1 overexpression. One mechanism through which Foxo1 affects mesenchymal cell differentiation into osteoblasts is through regulation of a key osteogenic transcription factor, Runx2. Indeed, our results show that Foxo1 directly interacts with the promoter of Runx2 and regulates its expression. Using a tibia organ culture model, we confirmed that silencing Foxo1 decreases the expression of Runx2 and impairs bone formation. Furthermore, our data reveals that Runx2 and Foxo1 interact with each other and cooperate in the transcriptional regulation of osteoblast markers. In conclusion, our in vitro, ex vivo, and in vivo results strongly support the notion that Foxo1 is an early molecular regulator in the differentiation of mesenchymal cells into osteoblast.

Opiates and elderly: use and side effects.

The evaluation of pain and the subsequent issue of pain control is a clinical challenge that all healthcare providers face. Pain in the elderly population is especially difficult given the myriad of physiological, pharmacological, and psychological aspects of caring for the geriatric patient. Opiates are the mainstay of pain treatment throughout all age groups but special attention must be paid to the efficacy and side effects of these powerful drugs when prescribing to a population with impaired metabolism, excretion and physical reserve. In a random chart review of 300 US veterans, 44% of those receiving an analgesic also received opioids. The increasing use of opiates for pain management by healthcare practitioners requires that those prescribing opioids be aware of the special considerations for treating the elderly. This article will address the precautions one must take when using opiates in the geriatric population, as well as the side effects and ways to minimize them.

Individualizing recommendations for weight management in the elderly.

PURPOSE OF REVIEW: This review provides current strategies for weight management in the elderly population as it can be different from young adults due to multiple factors: co-morbidities, polypharmacy, limitation of functional activities, social issues. RECENT FINDINGS: The recommendations for weight management for all age groups include exercise, diet, pharmacotherapy and surgery. In the elderly population, because of changes in age-related body composition, reduced energy requirement and expenditure, the standard young adult recommendations cannot be applied directly. The goal of weight management in the elderly differs from the young adult. The preferred method is maintenance of weight rather than aggressive weight loss with achieving a healthy, functional, and good quality of life. SUMMARY: The growing prevalence of obesity in the elderly population is becoming a major health problem and can affect functional status, can contribute to frailty and decline in activity, as well as worsening co-morbid medical problems. Practical recommendations for weight management in the elderly are challenging because of the obesity paradox in the elderly, and the lack of substantial research in this population. Individualized recommendations should be considered for elderly patients with a focus on the underlying medical problems, functional status and living environments.

Ultrasound-guided, vacuum-assisted excision in the diagnosis and treatment of clinically benign breast lesions.

INTRODUCTION: Ultrasound-guided, vacuum-assisted biopsy has a definitive role in the diagnosis of breast lesions. Its role in the treatment of benign breast lesions like fibroadenomas has not been established. PATIENTS AND METHODS: This is a retrospective review of patients undergoing ultrasound-guided, vacuum-assisted biopsy for clinically benign breast lesions. The procedures were performed in all cases by two consultant radiologists with special interest in breast radiology between February 2002 and January 2004. Patients were followed up in the clinic 6 weeks after the procedure. RESULTS: Seventy-six patients had ultrasound-guided, vacuum-assisted excision of clinically benign breast lesions during this 2-year period. Mean age of the patients was 31 years. Altogether, 86 procedures were performed. Six patients with larger lesions (> 2 cm) had two procedures on separate sitting and 4 patients had separate lesions excised on a later date. Fifty-six patients were identified to have fibroadenomas and had complete excisions as evidenced on scan. Three out of nine patients identified with equivocal disease on fine needle aspiration cytology (FNAC) were found to have cancer following ultrasound-guided, vacuum-assisted excision. One patient who was diagnosed with cancer on FNAC, proved to be fibroadenoma on final histopathology. Four patients developed haematomas following ultrasound-guided, vacuum-assisted excision and all were managed conservatively. CONCLUSIONS: Our study shows that ultrasound-guided, vacuum-assisted excision can play an efficient role in the diagnosis of benign breast lesions and is a safe and successful alternative in treatment of fibroadenomas.

Knowledge and beliefs on corneal donation in Singapore adults.

AIM: To assess the knowledge and willingness of Singapore adults towards corneal donation. METHODS: The study population consists of a cluster random sample of the population living in Bedok North (an area in the eastern part of Singapore). The study population comprised residents aged 21-65 years living in 675 randomly sampled housing units. The participation rate was 65.9% (544/825). All participants were interviewed face to face with a questionnaire formulated according to the modified Horton and Horton model. Knowledge, values, attitudes, and spiritual beliefs of participants were assessed to evaluate their willingness to donate their corneas. RESULTS: 67.0% of participants were willing to donate their corneas. Ethnicity (Chinese) and religion (Christians, Hindus, or those with no religion) were associated with increased willingness to donate corneas. Greater knowledge and increased altruistic values were also associated with increased willingness to donate corneas. CONCLUSION: A proportion of participants were willing to donate their corneas. Awareness of corneal donation is high but specific knowledge should be further increased among adults.

TIA-1+ cytotoxic large T-cell lymphoma of the mediastinum: case report.

A 52-year-old previously healthy Caucasian woman presented with superior vena cava syndrome, secondary to compression of a bulky anterior mediastinal mass involving the right lung. Fine-needle aspiration biopsy of the mediastinum yielded large epithelioid cells intermingled with small mature lymphocytes. The epithelioid cells are LCA positive, expressing cytoplasmic CD3 diffusely and TIA-1 focally, but negative for EMA, CD4, CD8, CD15, CD20, CD30, and CD56. The TIA-1+ cytoplasmic granules correlated to the azurophilic granules in Diff-Quik-stained cells, pink granules in Ultrafast Papanicolaou-stained cells, and dense core granules in electron microscopy. In situ hybridization for Epstein-Barr viral RNA was negative. The background small lymphocytes were composed of a majority of CD4+ T-lymphocytes and minority of CD8+ T-lymphocytes. The patient responded well to six cycles of CHOP chemotherapy, followed by radiation with a total dose of 4140 cGy delivered to the mediastinum in 23 fractions. On the chest X-ray taken 6 mo later, there was minimal apical fibrosis with no evidence of an acute intrathoracic pathology. To the best of our knowledge, this case may be the first report of cytotoxic large T-cell lymphoma of the mediastinum.

Acceptance of short course artesunate plus mefloquine drug combination by malaria patients in rural Myanmar.

A cross sectional study was carried out in a rural area of Myanmar to identify malaria patients' acceptance of artesunate plus mefloquine drug combination and to determine the cost borne by patients. The majority (88.5%) preferred this new regimen rather than the other ones they had used before; conviction of drug efficacy was the reason given for the preference by most of them. Traveling on foot to rural health centers or a health assistant's residence for getting the drugs was found to be the main route. Average cost incurred by a patient to get the drug was found to be 274.22 Kyats. Among the cost items, drug cost was the highest item that they had used.

Influence of blister packaging on the efficacy of artesunate + mefloquine over artesunate alone in community-based treatment of non-severe falciparum malaria in Myanmar.

Three studies were carried out to determine the need, acceptability, and efficacy of adding mefloquine to artemisinin derivatives (AD) for the first-line treatment of uncomplicated falciparum malaria. The first was a retrospective study of 255 basic health workers which showed that their recommendation of AD to patients depended on their level of training. None of the paramedics/midwives and only 9% of 129 doctors had prescribed AD, and no one had recommended AD in combination with mefloquine; 72% of patients used courses that were too short for parasitological cure. To promote the addition of mefloquine to AD regimens we conducted intervention workshops with health care providers and subsidized the cost of mefloquine to patients. In the second study, we interviewed 200 patients before and after the intervention to evaluate drug compliance with full doses of AD and use of subsidized mefloquine. After the intervention, we found that only 3.6% had used mefloquine and 62% had taken non-curative doses of AD. In the third study, we provided blister packs of medication in daily doses and compared the intake of AD + placebo (158 patients) with that of AD + mefloquine (222 patients) for 5 days. The compliance with both regimens was 99%. Blood smears for parasites on day 28 showed one positive in the AD + mefloquine group and 7 positive in the AD group. We conclude that provision of blister packs of daily doses is a very effective way to improve compliance with short courses and drug combinations, but the efficacy of the combination in Myanmar in this particular study was only marginally higher than that of AD alone.

A simplified in vivo drug sensitivity test for malaria in the field.

The study was intended to develop a simple and reliable in vivo field test for monitoring of sensitivity of P.falciparum to antimalarials. The test is to be used as a built in sustainable monitoring system and applied at regular frequencies to provide guidance in developing a country-wide antimalarial drug policy. The study was conducted as a hospital based study in Mon State in Mudon, Kamawet and Pa-auk hospitals. The criteria matched malaria patients were treated with standard dosages of chloroquine, sulfadoxine-pyrimethamine and mefloquine and blood films were taken on days 0, 2, 3, 4, 7, 14 and 28. The assessment of the in vivo drug response of P.falciparum on days 2, 3 and 4 were compared with WHO standard 28 days and 7 day tests. The following successful tests were carried out for 7 days with different antimalarials: 171 tests with chloroquine and sulfadoxine-pyrimethamine and 167 tests with mefloquine. Tests were also carried out for 28 days: 59 tests with chloroquine, 77 tests with sulfadoxine-pyrimethamine and 78 tests with mefloquine. The results found that 3 day tests, taking blood films on days 0 and 3, can be reliably used as an adjunct to 28-day tests. Since the test is simple and can be used extensively and sustainably throughout the country and the results are applicable to be used for epidemiological purposes, the method is suggested for use as a built-in monitoring method for the malaria control program.

The use of personal protective measures in control of malaria in a defined community.

Malaria is one of the main health problems in the non-immune immigrant workers and army personnel of the malaria endemic areas in Myanmar. Due to changes in the vector bionomics and multiresistant strains of P. falciparum, chemoprophylaxis alone is not an effective means of control of malaria in them. So it is envisaged that the combined used of personal protective measures (deltamethrin impregnated bed-nets, scalves and hand-bands) and the chemoprophylaxis will be an effective means of control of malaria in the define group of people. The study also intended to find out the side effects of the deltamethrin and feasibility and acceptability of methods by the users. The study was conducted in Theini Township, Northern Shan State, from March to November 1993. The study population consisted of all ages of both sexes 554 and 440 persons in the test and control groups respectively. At the initial phase of the study, malaria infected persons from both the groups were treated. The experimental group received personal protective measures with impregnation of bed-nets using 25 mg ai/m2 of deltamethrin at 4 monthly intervals and the scarves and hand-bands at twice the concentration of the insecticides at monthly intervals. Chemoprophylaxis was given to both the groups at weekly intervals using age adjusted dosage of Pyrixine tablet (sulfadoxine-pyrimethamine). The parasitological, entomological, and epidemiological indices were collected at two month intervals in both the groups. The study clearly showed the impact of personal protective measures and chemoprophylaxis on malaria infection in the studied subjects. During the study period, the out patient malaria cases of the test group was 6% to 11.2% and that of the control group was 12% to 21.6% in Theini Hospital. The reinfection rate of the test group (0.9 to 4.7%) was also significantly lower than the control group (6.1 to 14.3%) from July to November. Acceptance of the treated bed-nets, scarves and hand-bands was high and good compliance was found in the follow up. The results of the study clearly showed that malaria can be controlled effectively in the defined group of persons for a malaria transmission season by using chemoprophylaxis and personal protective measures.

Non-fatal strangulation: an uncommon parachute-related accident.

A case of non-fatal strangulation of the neck by rigging lines of a parachute during military training is presented. It is an unusual but potentially life-threatening injury. Probable factors leading to such injury are discussed.

Gangrene of the penis.

A case of gangrene of the penis, rarely seen at our University Hospital is reported. Urolithiasis, urinary tract infection, infected piles and anaemia were found to be associated with the condition. Because of rapid spread of the gangrene, partial amputation was required in this reported case.

Ascaris cholecystitis and cholangitis: an experience in Myanmar.

Twenty-seven cases of ascaris cholecystitis and cholangitis were managed in a surgical unit of a general hospital in Yangon, Myanmar, from January 1989 to March 1990. Nineteen women and eight men with a mean age of 42 years were studied. Main clinical manifestations were right hypochondrial pain, fever, chills, rigors, nausea, vomiting and jaundice. Diagnosis was established by abdominal ultrasonograms in all cases. Laparotomy was performed in all cases because of failure to respond to initial conservative treatment. Live and dead ascarids were found in the gall bladder and biliary ductal system. Cholecystectomy, bile duct exploration, worm extraction and T-tube drainage were done in all cases. There were no deaths. Two patients developed minor wound sepsis. During the follow-up period ranging from 3 to 12 months, there was no recurrence of symptoms in all patients. All patients were given antihelminthics before discharge and three weeks later.

Bilio-enteric anastomoses: results in benign and malignant conditions.

Twenty bilio-enteric anastomoses were performed or managed from May 1990 to December 1992. Recurrent pyogenic cholangitis (RPC) and pancreatic cancer were the commonest conditions which required drainage procedures. Roux-en-Y hepatico-jejunostomy (RHJ) was performed in 9 patients, 4 for RPC, one for pancreatic cancer, another for a cholangiocarcinoma, 2 following excision of choledochal cyst and one hepatico-jejunostomy was part of a Whipple reconstruction. Roux-en-Y side to side choledocho-jejunostomy (CDJ) was performed in one patient. Choledocho-duodenostomy (CDD) was performed in 6, 4 for obstructive jaundice due to choledocholithiasis, one for RPC and one in a choledochal cyst. One patient operated elsewhere presented with complications after a CDD. Palliative cholecysto-jejunostomy (CYJ) was carried out in 4 patients with pancreatic malignancy. All benign conditions were treated by hepatico-jejunostomy and choledocho-duodenostomy, while three patients with malignant conditions were treated by hepatico-jejunostomy. Permanent subcutaneous access loops were provided when recurrent problems were anticipated, 4 in RPC and one after subtotal resection of a cholangiocarcinoma. Based on this study, we found Roux-en-Y hepatico-jejunostomy a versatile drainage procedure, which was useful in both benign and malignant diseases.

Renal histopathology following Russell's viper (Vipera russelli) bite.

Renal lesions in ten patients following Russell's viper bite were studied. Renal biopsies were available in six and autopsies in four patients. Autopsied tissues from two cases of traumatic death served as controls. Both qualitative and quantitative changes in the glomeruli, tubules, interstitium and blood vessels were evaluated. Tubular necrosis was detected in five, tubular degeneration in nine, glomerular changes in nine and interstitial changes in four cases. Generally tissues from expired cases had more severe and extensive renal lesions than those that survived.