Isoniazid-induced encephalopathy in an end-stage renal disease patient - A case report and literature review.

Patients with end stage renal disease have higher risk of tuberculosis due to lower cell-mediated immunity. Standard regime of anti-tuberculosis contains isoniazid where neurological side effects such as seizure and encephalopathy have been documented. We present a case of isoniazid-induced encephalopathy in a haemodialysis patient. A literature review on isoniazid-induced encephalopathy was done. Recognition of this condition is important as it is reversible with cessation of isoniazid and institution of high dose pyridoxine.

POEMS syndrome: A rare paraneoplastic presentation of spinal plasmacytoma.

The acronym POEMS syndrome was coined for a unique multisystem disorder characterised by peripheral neuropathy, organomegaly, endocrinopathies, monoclonal gammopathy and skin changes. We report a male patient presenting to us with spinal plasmacytoma complicated with paraplegia. He was subsequently diagnosed to have POEMS syndrome and successfully treated with thalidomide and dexamethasone. Post treatment, he is able to ambulate independently.

Important differential in a patient presenting with neuropsychiatric symptoms: Anti-N-Methyl-D-Aspartate receptor encephalitis.

Anti-N-Methyl-D-Aspartate receptor (NMDAR) encephalitis is an immune mediated condition, which remains relatively unknown in Malaysia outside tertiary hospitals with neurology unit. It is often misdiagnosed as a psychiatric illness before definitive treatment is instituted. We report here an 18-year-old man who initially presented to the psychiatry unit before he was subsequently diagnosed as having anti-NMDAR encephalitis. To our knowledge, this is the first reported case of anti-NMDAR encephalitis in the east coast of Peninsular Malaysia.

The impact of sink removal and other water-free interventions in intensive care units on water-borne healthcare-associated infections: a systematic review.

With increasing awareness of water sinks as potential sources of outbreaks and transmission of multi-drug resistant (MDR) bacteria in intensive care units (ICUs), there is growing interest in water-free patient care systems. This systematic review reviewed and synthesized available evidence on the effectiveness of sink removal with or without water-free activities in the ICU environment to reduce water-borne healthcare-associated infections. We searched five databases (PubMed, MEDLINE, Scopus, Web of Science and Embase) for studies published from 1st January 1980 to 2nd April 2024 that examined water-less or water-free activities in the ICU to reduce healthcare-associated infections and patient colonization. Of 2075 articles, seven quasi-experimental studies (total: 332 patient beds) met the study selection criteria. Six of these seven studies (85.7%) were based in adult ICUs; one (14%) was in a neonatal ICU. Five of seven sites (71.4%) implemented water-less interventions after an outbreak. Water-free alternatives used included water-less bath products (six of seven; 85.7%), bottled water for consumption (three of seven; 42.9%), oral care (three of seven; 42.9%) and dissolving of oral medication (four of seven; 57.1%), designated 'contaminated' sink outside of patient and medication preparation areas for disposal of wastewater (four of seven; 57.1%). Implicated pathogens studied included MDR Gram-negative bacteria (four of seven; 57.1%), MDR Pseudomonas aeruginosa only (two of seven; 28.6%), and pulmonary non-tuberculous mycobacterium (NTB) (one of seven; 14.3%). Five of seven (71.4%) studies reported outbreak cessation. Preliminary evidence, from a limited number of studies of which the majority were conducted in an outbreak setting, suggest that sink removal and other water-free interventions in the ICU helped terminate outbreaks involving taps and decrease hospital-onset respiratory isolation of pulmonary NTB.

Knowledge, attitudes, practices, and perceived challenges for healthcare workers on waterless intensive care unit (ICU) care at a neonatal ICU in Singapore.

BACKGROUND: Implementation of waterless care, including removal of sinks from patient care areas, is an emerging approach to reduce waterborne infections in high-risk areas such as intensive care units (ICUs). This approach, however, requires significant changes from traditional infection control practices and acceptance by healthcare workers (HCWs) for successful transition. AIM: To explore the knowledge, attitudes, practices (KAPs), and perceived challenges of HCWs who transitioned from working in a unit with standard infection control practices to one with waterless ICU care practices. METHODS: The study was conducted using a customized 30-item self-reported survey instrument administered to HCWs working in tertiary neonatal units at a single hospital. FINDINGS: Participation rate was 88.6% (101/114), comprising 66.3% (67/101) nurses, 31.0% (31/101) doctors, and 3.0% (3/101) allied health professionals; 90.1% (91/101) had positive attitudes and 53.5% (54/101) had good knowledge regarding waterless ICU care; 83.1% (84/101) followed the appropriate practice of hand hygiene when their hands were visibly soiled. Main challenges with waterless ICU care were perceived compromise of personal (46.5% (47/101)) and patient (22.8% (23/101)) hygiene. A total of 43.6% (44/101) reported an increase in skin-related conditions: 10.9% (11/101) had to visit a doctor for this reason, of whom 64.0% (7/11) had pre-existing skin conditions. CONCLUSION: Despite overall good attitudes and practices toward waterless ICU care, HCWs may have specific concerns related to hygiene and skin conditions which need to be addressed. For units transiting to waterless ICU care, similar surveys may provide valuable information by identifying gaps in KAP to improve compliance.

Measurement of biomarkers in juvenile idiopathic arthritis patients and their significant association with disease severity: a comparative study.

OBJECTIVE: To evaluate in juvenile idiopathic arthritis (JIA) patients a biomarker panel of anti-cyclic citrullinated peptide (anti-CCP) antibodies, cartilage oligomeric matrix protein (COMP), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), IgM rheumatoid factor (RF), IgG RF, and IgA RF and compare to the presence of joint erosions (JE), joint space narrowing (JSN), and synovitis in order to evaluate aggressive disease. METHODS: Sixty-eight JIA patients (19 RF positive polyarthritis, 23 RF negative polyarthritis, 17 persistent oligoarthritis, and 9 systemic-onset) were evaluated using the biomarker panel and compared to 18 healthy controls. All RF isotypes, anti-CCP antibodies, and COMP were measured by enzyme-linked immunosorbent assays (ELISA). Statistically significant differences and associations were assessed for each biomarker in relation to JE, JSN, and synovitis. Multiple regression analysis was used to find the variables associated with joint damage and synovitis. RESULTS: Patients with JE and JSN had significantly elevated levels of IgA RF, IgM RF, and anti-CCP antibodies. COMP levels were higher in early disease, but also later in disease in patients with no JE or JSN. ESR, CRP, and IgA RF were significantly elevated in patients with active synovitis. Regression analysis showed IgM RF and disease duration to be associated with JE and JSN. Anti-CCP antibodies and COMP were also associated with JSN. CRP and IgA RF were associated with synovitis. CONCLUSION: Our findings demonstrate the importance of measuring IgM RF and IgA RF by ELISA and anti-CCP antibodies by ELISA, in addition to COMP in the assessment of JIA patients to determine severity of disease.

A role for the complement system in rheumatoid arthritis.

The production of autoreactive antibodies from self-reactive B cells results in the formation of immune complexes that deposit in tissue and fix complement, contributing to the pathogenesis of rheumatoid arthritis (RA). Earlier mouse models emphasize the importance of autoreactive antibodies formed against "self" proteins that serve as a source for T cell-mediated immune response, stemming from cross-reactivity and resulting in B cell activity. However, more recent models suggest the need for both autoantibodies and the initiation of the inflammatory cascade via the alternative complement pathway, which is unbridled as the cartilage lacks the usual regulatory proteins of the complement system. Furthermore, deficiencies in specific complement proteins could lead to an escape from negative selection by these self-reactive B cells. Moreover, the classical complement pathway establishes chemotactic gradients by which inflammatory cells follow and accumulate in the synovial fluid where they engulf immune complexes and release proteolytic enzymes. In addition, the processing of circulating immune complexes either via Fc receptor or CR1 and opsonization by complement fragments plays a key role in determining the fate of immune status. In addition, complement proteins are a major determinant in the size and solubility of an immune complex, which also affects clearance. The evidence regarding intra-articular activation of the complement system in RA provides the possibility to pharmacologically manipulate various parts of the complement system for therapeutic purposes and potential therapeutic targets for the control of inflammation and the prevention of joint destruction.

Plasma catecholamines and oxygen consumption during weaning from mechanical ventilation.

Previous studies on oxygen consumption (VO2) during weaning from mechanical ventilation assumed that an increase in VO2 (delta VO2) reflected oxygen consumption by respiratory muscles (VO2RESP), and proposed delta VO2 as a weaning predictor. We measured VO2 CO2 production (VCO2) and plasma catecholamines in 20 short-term ventilated patients during weaning by SIMV and CPAP. delta VO2 as a percentage of VO2 during spontaneous ventilation (delta VO2%) ranged from 4.8% to 41.5%. VCO2 also increased and correlated with VO2. Plasma adrenaline and noradrenaline increased significantly to levels known to produce considerable increases in metabolic rate. Mean arterial pressure and heart rate concomitantly increased, but spontaneous minute ventilation decreased. Thus, since the increased plasma catecholamines are calorigenic, the assumption that delta VO2 represents VO2RESP is incorrect. Although mean delta VO2% of successfully weaned patients was significantly less than that of failure-to-wean patients, the wide scatter of individual values in the latter group excludes delta VO2% as an accurate weaning predictor.

The gene encoding ammonia monooxygenase subunit A exists in three nearly identical copies in Nitrosospira sp. NpAV.

The gene encoding ammonia monooxygenase subunit A (AmoA) was found in three copies of the genome of the chemolithotrophic soil bacterium, Nitrosospira sp. NpAV. The open reading frame and flanking regions of the three copies were isolated from digested size fractionated genomic DNA using oligodeoxyribonucleotide primers and polymerase chain reaction. The three gene copies of amoA were sequenced and the sequences compared to each other. The open reading frames and the upstream and downstream flanking regions were nearly identical in the three copies. All three copies were expressed in recombinant Escherichia coli strains from the indigenous promoter producing a product of approximately 30 kDa. All amoA copies encode 274 amino acid polypeptides which have similarity to the ammonia monooxygenase acetylene-binding protein from Nitrosomonas europaea.

Anesthetic management of renal cell carcinoma with inferior vena caval extension.

We present a case of a patient with renal cell carcinoma extending into the inferior vena cava. Preoperative diagnosis was facilitated by transthoracic and transesophageal echocardiography (TEE), and inferior venacavography. Intraoperatively, monitoring with continuous TEE was used. Preparation was made for cardiopulmonary bypass but surgery was successfully completed using extracorporeal venous shunting. We discuss the important aspects of preoperative diagnosis and the intraoperative anesthetic management of this case.

Necrotising soft tissue infections as a complication of chickenpox.

Varicella gangrenosum, in which a necrotising soft tissue infection complicates the vesicular eruption of chickenpox, is rare. The condition may have devastating sequelae including disseminated intravascular coagulation and death. Survival is dependent on early diagnosis, adequate antibiotic coverage and, particularly, early surgical debridement. Three cases of varying severity are presented here together with a review of the available literature.

A successful peritoneovenous shunting of ascites using the great saphenous vein.

For the surgical palliation of massive ascites, a LeVeen or Denver shunt may be implanted to drain ascitic fluid from the peritoneal cavity into the circulation. But all commercial shunts are costly and depend on a synthetic valve to prevent blood refluxing into the peritoneal cavity. We report here the first patient with a malignant ascites that was successfully palliated by peritoneovenous shunting using the great saphenous vein as a biological valve.

An unusual presentation of carcinoma of the gallbladder--case report.

Unusual modes of presentation of carcinoma of the gallbladder have been described in the literature. However, this is probably the first reported case of carcinoma of the gallbladder presenting with acute large bowel obstruction. This paper also reviews the literature pertaining to the clinical features and current treatment of carcinoma of the gallbladder. It continues to be a discouraging disease characterised by late diagnosis and a poor outcome.

Differences in cognitive complexity of adolescents with foreclosed and achieved identity status.

The purpose of this study was to assess whether the complexity of the self-concept differs based on identity status in late adolescence. Adolescents in the achieved status have a strong sense of identity that has emerged following an intense period of exploration. Adolescents in the foreclosed status also have a strong sense of identity, but they have never been through a period of exploration. It was expected that adolescents in the achieved status would have more complex self-concepts than those in the foreclosed status. 62 university students were classified into the achieved or foreclosed identity status based on their scores on the Extended Version of the Objective Measure of Ego Identity Status-2. They then completed a trait sort to measure the complexity of their self-concepts. Complexity scores were calculated based on the H statistic, an index of dispersion derived from information theory. The results were as expected. Possible structural changes underlying the process of developing identity are presented, and the usefulness of structural self-concept models for studying development of identity is examined.

Abnormal kappa:lambda light chain ratio in circulating immune complexes as a marker for B cell activity in juvenile idiopathic arthritis.

Patients with juvenile idiopathic arthritis (JIA) have been shown to have elevated levels of circulating immune complexes (CICs) which correlated with disease activity. Our aim was to assess B cell activity by measuring the amount of and the kappa:lambda chain immunoglobulin light (L) chain ratio in CICs from JIA patients and to determine potential evidence for either an antigen-driven response or B-cell receptor editing. We used an enzyme-linked immunosorbent assay to measure kappa and lambda chains present in the CICs from the sera of patients with JIA. Statistical analysis was performed using Pearson's correlation, one-way ANOVA and Bonferroni post hoc analysis. Sera from 44 JIA patients were examined for the concentration of L chains in CICs. Healthy controls had a kappa:lambda chain ratio of 1.2:1, whereas this ratio was reversed among JIA subgroups with RF-positive polyarthritis (1:1.2), RF-negative polyarthritis (1:1.3), oligoarthritis (1:2.3) and systemic-onset arthritis (1:2.5). In addition, overall lambda chain selection was not significantly associated with a particular immunoglobulin heavy (H) chain and occurred with all immunoglobulin isotypes. We showed preferential selection of lambda chains contributing to the formation of potentially pathogenic CICs from JIA patients, of all onset types compared to healthy controls, in an H chain-independent manner. The reversal of kappa:lambda chain ratio within the JIA CICs and association with all immunoglobulin isotypes demonstrated the potential for L chain editing. Furthermore, we conclude that a reversal of the normal kappa:lambda chain ratio in JIA CICs may be used as a marker for increased B-cell activity.

A body-worn delayed auditory feedback fluency aid for stammerers.

Body-worn fluency aiming to relieve the disability of stammering during periods of use (just as spectacles correct defective vision only while worn, and make no claim to treat or cure the disability) have been envisaged for a quarter of a century. Most have been based on Auditory feedback Masking, but the Aid described here is probably the first body-worn version to be based on the principle of Delayed Auditory Feedback, recognised for 20 years as an aid to fluency, but hitherto available only in desk-top equipment. The embodiment described here fits easily into a breast pocket and is wired to a tie-pin microphone and two standard hearing aid earpieces. Voice actuated switching enables other speakers to be heard clearly and undelayed. Results of early clinical trials are indicated.

Australian farm work injuries: incidence, diversity and personal risk factors.

Information on farm work-related injuries was sought to assist in the design of effective farm safety prevention programs. A telephone survey was conducted using a stratified random sample of 919 sheep/wool, beef cattle and dryland broadacre cropping farms from three shires in the wheat/sheep belt of New South Wales. The adjusted response rate was 84%. There were 425 reported injuries over an 18-month period. One in five farms reported at least one injury per year, while one in 12 farms reported at least one serious injury per year. Animal-related injuries were the largest major category for agent of injury, while the largest category for nature of injury was sprain and strain, recording almost one-quarter of all injuries. The farm workshop or shed was the most common location of injury, with more than 20% of all reported injuries occurring there. Personal risk factors thought to contribute to these farm work-related injuries were examined. The statistically significant personal risk factors for injury occurrence were age (and/or experience), previous injury status, body mass index, hours of sleep, a variable measuring daytime drowsiness and a variable measuring perceived stress.

Plasma concentrations of catecholamines following adrenaline infiltration during gynaecological surgery.

High pressure liquid chromatography with electrochemical detection has been used to measure plasma catecholamine concentrations in six gynaecological patients undergoing halothane anaesthesia for cervical cone biopsy. Mean catecholamine concentrations before infiltration were 1.01 +/- 0.23 (SEM) nmol litre-1 (185 +/- 43 pg ml-1) for adrenaline, and 2.2 +/- 0.25 nmol litre-1 (364 +/- 41 (185 +/- 43 pg ml-1) for adrenaline, and 2.2 +/- 0.25 nmol litre-1 (364 +/- 41 pg ml-1) for noradrenaline. Following infiltration with 0.5% bupivacaine 15 ml with adrenaline 1:200 000, plasma adrenaline concentrations increased to a mean peak concentration of 18.6 +/- 3.7 nmol litre-1 (3.4 +/- 0.69 ng litre-1). The lack of sympathoneuronal response was confirmed by simultaneous measurements of plasma noradrenaline concentrations, which did not change significantly. The proportion of the injected adrenaline measured in the intravascular compartment was 21.8%. The significance of intravascular absorption of exogenous adrenaline is discussed in relation to the use of halothane anaesthesia and the concurrent injection of a local anaesthetic solution.

Plasma catecholamine levels during functional endoscopic sinus surgery.

Plasma adrenaline and noradrenaline concentrations were measured in 10 consecutive patients during functional endoscopic sinus surgery (FESS). Surgery was preceded by nasal packing with 5 ml 2% cocaine solution, followed by infiltration with 1:80,000 adrenaline and 2% lignocaine. All patients showed a marked rise in plasma adrenaline concentration within 4 min of commencing infiltration, which was not related to the patient's sex, age, weight, the total amount injected, nor the amount injected into the nose. Surgeons should be aware of this marked, but unpredictable, systemic absorption of locally infiltrated vasoconstrictors. Pulse and ECG monitoring should be considered mandatory for such procedures, even when surgery is performed under local anaesthesia.

Hemodynamic and hepatic effects of methohexital infusion during nitrous oxide anesthesia in humans.

The hemodynamic effects of methohexital, at infusion rates of 60-65 and 120 micrograms/kg/min with concomitant inhalation of 67% nitrous oxide in oxygen, have been studied during spontaneous and controlled ventilation in 8 patients. Under most of the conditions studied methohexital infusion anesthesia was associated with lower arterial pressure (-13% to -33%) than in the awake state, decreased cardiac output (-26% to -38%), and increased systemic vascular resistance (+5% to +37%) during surgery, but also with decreased cardiac output (-25%) and decreased systemic vascular resistance (-13%) during anesthesia without surgery. The higher infusion rate was not associated with decreases in arterial pressure or cardiac output during either spontaneous or controlled ventilation. The hemodynamic response to laryngoscopy and intubation was poorly suppressed by methohexital in that peak arterial pressures exceeded the preanesthetic values by 33%. No evidence of impaired hepatocellular function was found after infusions of methohexital lasting up to 4 h.