Detection of Atrial Fibrillation After Ischemic Stroke with an Insertable Cardiac Monitor: A Systematic Review and Individual Patient Data Meta-Analysis of Randomised Clinical Trials.

OBJECTIVE: In ischemic stroke patients, we compared the use of insertable cardiac monitor (ICM) versus non-ICM methods of cardiac monitoring on the incidence of atrial fibrillation (AF) detection and other clinical outcomes. BACKGROUND: Current guidelines recommend the routine use of 12-lead electrocardiography or Holter monitoring for AF detection after ischemic stroke. Recent randomised controlled trials have investigated the impact of ICM versus non-ICM methods of cardiac monitoring for AF detection in this population. However, precise recommendations for monitoring post-stroke AF are lacking; including the optimal timing, duration, and method of electrocardiography monitoring. METHODS: A systematic search was conducted on Embase and PubMed from database inception until 27 October 2022 to include randomised controlled trials that compared ICM with non-ICM methods of cardiac monitoring for post-stroke AF detection. This yielded 3 randomised controlled trials with a combined cohort of 1231 patients with a recent ischemic stroke. Individual patient data (IPD) was then reconstructed from Kaplan-Meier curves and analysed using the shared-frailty Cox model. An aggregate data meta-analysis was conducted for 1231 patients across all 3 studies for outcomes that could not be reconstructed using IPD. RESULTS: One-stage meta-analysis demonstrated an increase in the hazard ratio (HR 6.01, 95% CI 3.40-10.60; p<0.001) of AF detection in patients undergoing monitoring via ICM compared to standard care. Aggregate data meta analysis revealed a significant increase in initiation of anticoagulation (OR 3.09, 95% CI 2.05 - 4.66; p<0.00001) in the ICM group. However, no significant differences in the incidence of recurrent ischemic stroke, transient ischemic attack or death were found. CONCLUSIONS: In this meta-analysis, we found that the use of ICM increased the detection rate of post-stroke AF and the rate of anticoagulation initiation. However, this did not translate into a reduced incidence of recurrent ischemic stroke.

A prospective study of incidence and outcome of acute kidney injury among hospitalised patients in Malaysia (My-AKI).

INTRODUCTION: The incidence of acute kidney injury (AKI) among hospitalised patients has not been well studied in Malaysia. MATERIALS AND METHODS: We conducted a prospective, multicentre study in seven hospitals in West Malaysia. All the adults admitted in March 2017 fulfilling Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI were included. RESULTS: Of the 34,204 patients screened, 2,457 developed AKI (7.18%), 13.1% of which occurred in intensive care unit (ICU). There were 60.2% males with a mean age of 57.8 (±17.5) years. The most common comorbidities were hypertension (55.0%), diabetes (46.6%), ischaemic heart disease (15.1%) and chronic kidney disease (12.0%). The commonest causes of AKI were sepsis (41.7%), pre-renal (24.2%) and cardiorenal syndrome (10.8%). Nephrotoxin exposure was reported in 31%. At diagnosis, the proportion of AKI stages 1, 2 and 3 were 79.1%, 9.7%, 11.2%, respectively. Referral to nephrologists was reported in 16.5%. Dialysis was required in 176 (7.2%) patients and 55.6% were performed in the ICU. Acidosis (46.2%), uraemia (31.6%) and electrolyte disturbance (11.1%) were the commonest indications. Continuous renal replacement therapy (CRRT) was required in 14%. The average length of hospital stay was 9.5 days. In-hospital mortality was 16.4%. Among survivors, full and partial renal recovery was seen in 74.7% and 16.4% respectively while 8.9% failed to recover. After a mean follow-up of 13.7 months, 593 (30.2%) of survivors died and 38 (1.9%) initiated chronic dialysis. Mortality was highest among those with malignancies (Hazard Ratio, HR 2.14), chronic liver disease (HR 2.13), neurological disease (HR 1.56) and cardiovascular disease (HR 1.17). CONCLUSION: AKI is common in hospitalised patients and is with associated high mortality during and after hospitalisation.

'Occupational dermatoses from Personal Protective Equipment during the COVID-19 pandemic in the tropics - A Review'.

The COVID-19 pandemic has enveloped the world and there has been a high incidence of occupational dermatoses related to Personal Protective Equipment (PPE) amongst healthcare workers (HCWs) during this period. Prevention and management of these conditions will not only improve staff morale and quality of life, but will also minimize the risk of breaching PPE protocol due to such symptoms. The tropical climate in Singapore predisposes HCWs to more skin damage and pruritus due to intense heat, high humidity and sun exposure. The effects of friction, occlusion, hyperhidrosis and overheating on the skin in the tropics should not be neglected. Preventive measures can be taken based on our recommendations, and the working environment can be made more conducive for frontline HCWs. We review the literature and discuss various preventive and management strategies for these occupational skin diseases for our frontline HCWs, especially those working in less controlled working environments beyond the hospital in Singapore. Shorter shifts and frequent breaks from PPE are recommended. Duration of continuous PPE-usage should not exceed 6 h, with breaks in non-contaminated areas every 2-3 h to hydrate and mitigate the risk of skin reactions. Other strategies, such as teledermatology, should be considered so that consultations can remain accessible, while ensuring the safety and well-being of our clinical staff.

Photoprotection according to skin phototype and dermatoses: practical recommendations from an expert panel.

Increasing evidence on the impact of the different wavelengths of sunlight on the skin demonstrates the need for tailored recommendations of sunscreen according to skin phototype and dermatoses, which is now possible due to advances in the filters and formulations of sunscreens. A selective literature search was performed by an international expert panel, focusing on the type of sunscreen to recommend for photoaging, skin cancers, photodermatoses, pigmentary disorders and skin inflammatory disorders. Protection against ultraviolet (UV)B is especially important for light skin as there is a high risk of sunburn, DNA damage and skin cancers. Darker skin may be naturally better protected against UVB but is more prone to hyperpigmentation induced by visible light (VL) and UVA. Protection against UVA, VL and infrared A can be helpful for all skin phototypes as they penetrate deeply and cause photoaging. Long-wave UVA1 plays a critical role in pigmentation, photoaging, skin cancer, DNA damage and photodermatoses. Adapting the formulation and texture of the sunscreen to the type of skin and dermatoses is also essential. Practical recommendations on the type of sunscreen to prescribe are provided to support the clinician in daily practice.

Atypical meningioma with nodal metastasis: A case report.

INTRODUCTION: Meningiomas are common and usually benign central nervous system neoplasms. These neoplasms are graded into three groups which differ in biological behaviour. Atypical meningioma is an intermediate grade (Grade 2) tumour that is rarely associated with metastases compared to higher grade (Grade 3) meningiomas. CASE REPORT: A 68-year-old lady with a history of multiple craniotomies and hemifacial resections for meningothelial meningioma currently underwent orbital exenteration, tumour debulking and cervical nodal excision for tumour recurrence. Histopathological examination of the tumour showed atypical meningioma, with cervical nodal metastasis. DISCUSSION: This case report presents a rare finding of lymph node metastasis associated with atypical meningioma. The previous history of surgical resection is a known risk factor for metastasis for low to intermediate grade meningioma. Tumour biology and histology are predictors of metastasis. Haematogenous dissemination is the commonest route of metastasis. No standardised management protocol has been developed and the prognosis remains unknown.

Identification of Trichosanthes associated rhabdovirus 1, a novel member of the genus Cytorhabdovirus of the family Rhabdoviridae, in the Trichosanthes kirilowii transcriptome.

The genome sequence of a novel RNA virus, Trichosanthes associated rhabdovirus 1 (TrARV1), was identified in a transcriptome dataset isolated from a root sample of Trichosanthes kirilowii, which is a flowering plant belonging to the family Cucurbitaceae. The fruits, seeds, and root tubers of T. kirilowii have been used clinically in traditional Chinese medicine. The TrARV1 genome sequence was predicted to have six open reading frames (ORFs) encoding five canonical structural proteins of the family Rhabdoviridae (N ORF for nucleocapsid, P ORF for phosphoprotein, M ORF for matrix protein, G ORF for glycoprotein, and L ORF for polymerase), and an accessory protein. Sequence comparisons and phylogenetic analyses based on L and N proteins confirmed that TrARV1 is a novel member of the genus Cytorhabdovirus of the family Rhabdoviridae. TrARV1 is most closely related to Wuhan insect virus 5 and persimmon virus A. The putative cis-regulatory elements involved in transcription termination and polyadenylation, commonly found in the gene junction regions of rhabdoviruses, were also identified in the TrARV1 genome having the consensus sequence 3'- ACUAAAUUAUUUUGAUCUUU-5'. The genome sequence of TrARV1 may be useful to study the evolution and molecular biology of cytorhabdoviruses. Keywords: Trichosanthes associated rhabdovirus 1; Cytorhabdovirus; Rhabdoviridae; Trichosanthes kirilowii.

Identification of Pistacia-associated flexivirus 1, a putative mycovirus of the family Gammaflexiviridae, in the mastic tree (Pistacia lentiscus) transcriptome.

In this study, we identified the genome sequence of the novel virus Pistacia-associated flexivirus 1 (PAFV1), a putative member of the mycovirus family Gammaflexiviridae (the order Tymovirales), via analysis of a transcriptome dataset for the mastic tree (Pistacia lentiscus, the family Anacardiaceae). PAFV1 was predicted to have three open reading frames (ORFs): ORF1, encoding a replicase (REP) with RNA-dependent RNA polymerase activity; ORF2, a movement protein (MP); and ORF3, a hypothetical protein. The PAFV1 REP sequence showed high similarity to those of three known members of the family Gammaflexiviridae i.e., Entoleuca gammaflexivirus 1 (EnFV1), Entoleuca gammaflexivirus 2 (EnFV2), and Botrytis virus F (BVF). A genome contig of the fungus Monosporascus cannonballus also contained a sequence of an endogenous virus similar to that of PAFV1. Sequence comparison and phylogenetic analysis indicated that PAFV1, EnFV1, and the endogenous virus of M. cannonballus formed a distinct subgroup (apart from EnFV2 and BVF), and may be the founding members of a novel genus in the family Gammaflexiviridae. Notably, MP sequences of PAFV1/EnFV1 showed similarity to the MP sequences of the mycovirus group called tobamo-like mycoviruses (an unassigned taxon), implying that genomic recombination occurred between members of the family Gammaflexiviridae and tobamo-like mycoviruses. Since PAFV1 is phylogenetically related to mycoviruses, PAFV1 may also be a mycovirus that infected a fungus associated with the mastic tree sample, which is evidenced by the presence of fungal ribosomal RNA sequences in the mastic tree transcriptome. Thus, the PAFV1 genome sequence may be useful in elucidating the genome evolution of Gammaflexiviridae and tobamo-like mycoviruses. Keywords: Pistacia-associated flexivirus 1; Gammaflexiviridae; mycovirus, mastic tree.

The use of magnetic resonance phase-contrast cine in Chiari malformation with syringomyelia.

INTRODUCTION: Chiari malformation (CM) is a disorder of mesodermal origin and is commonly associated with syringomyelia. Foramen magnum decompression is the first-line of standard treatment in symptomatic patients with a confirmed radiographic diagnosis. Magnetic resonance (MR) cine allows accurate evaluation of cerebrospinal fluid (CSF) physiology at the craniovertebral junction but often this is under-utilised in Malaysia. METHODS: In this series, we looked into nine cases of CM with syringomyelia from clinical and radiological perspective before and after surgery. The radiological parameters were herniated tonsillar length, syrinx: cord ratio, syrinx length and diameter. Flow velocity and morphologic changes in Chiari were illustrated. RESULTS: Seven patients showed either reduction in syrinx length, syrinx: cord ratio or both postoperatively. Clinical recovery somewhat varied in motor and sensory symptoms. Four patients gained better functional grade in modified Rankin scale (MRS) while the rest remained similar. The study highlighted the advantage of CSF flow dynamics information over MR anatomical radiographic improvement in addressing the neurologic and functional recovery. We also discussed the practicality of cine sequence in preoperative patient selection, syrinx analysis and postoperative flow evaluation in anticipation of clinical outcome. CONCLUSION: Phase-contrast cine MRI is a useful tool dictated by resource availability. We recommend its routine use in preoperative analysis and subsequent observational follow-up after surgery.

Identification of a novel member of the family Betaflexiviridae from the hallucinogenic plant Salvia divinorum.

Betaflexiviridae is a family of plant-infecting RNA viruses with 11 recognized genera, of which genomes have diverse organization with three to six open reading frames (ORFs). A genome sequence of a novel Betaflexiviridae species, named Salvia divinorum RNA virus 1 (SdRV1), was identified in Salvia divinorum, herbal mint plant with hallucinogenic properties. The SdRV1 genome was predicted to have four ORFs encoding a replicase polyprotein (REP), a movement protein (MP), a coat protein (CP), and a putative nucleic acid-binding protein (NBP). Phylogenetic analyses based on the REP, MP, and CP sequences indicated that SdRV1 is most closely related to members of the genus Citrivirus. However, the genome organization of SdRV1 is the same as that of the genus Prunevirus. Moreover, the SdRV1 NBP had greatest sequence similarity with members of the genus Carlavirus. A complex evolutionary history involving ancestors of these three genera might have resulted in the unique phylogenetic position of SdRV1, which could be considered the founding member of a new genus in the family Betaflexiviridae. The genome sequence of SdRV1 might be useful for studies on the evolution of Betaflexiviridae. Keywords: Salvia divinorum RNA virus 1; Betaflexiviridae; Salvia divinorum.

Zostera virus T - a novel virus of the genus Tepovirus identified in the eelgrass, Zostera muelleri.

Analysis of a transcriptome dataset obtained from tissue samples of the eelgrass Zostera muelleri, an aquatic flowering plant species of the family Zosteraceae, yielded three genome sequence contigs of a novel RNA virus. Sequence comparison and phylogenetic analysis revealed that the novel RNA virus, named Zostera virus T (ZoVT), belongs to the genus Tepovirus of the family Betaflexiviridae. The three genome contigs of ZoVT showed 88.2‒97.2% nucleotide sequence identity to each other, indicating that they descended from a common ancestor. The ZoVT genome contains three open reading frames (ORFs): ORF1 encodes a 1816 amino acid (aa) replicase (REP) with RNA-dependent RNA polymerase (RdRp) activity; ORF2, a 398 aa movement protein (MP); and ORF3, a 240 aa coat protein (CP). The phylogenetic analysis using REP sequences of ZoVT and other Betaflexiviridae viruses showed that Prunus virus T is the closest known virus to ZoVT, whereas potato virus T, the type species of the genus Tepovirus, is the second closest virus. Genome sequences of ZoVT, which is the third tepovirus species identified to date, may be useful for investigating the evolution and molecular biology of tepoviruses. Keywords: Zostera virus T; Tepovirus; Betaflexiviridae; eelgrass; Zostera muelleri.

A Further Test of the Impact of Online Gaming on Psychological Wellbeing and the Role of Play Motivations and Problematic Use.

The impact of increased online gaming play time on psychological wellbeing was examined focusing on the Multiplayer Online Battle Arena (MOBA) game genre. This relationship was explored with respect to motivators for playing and resilience factors. A cross-sectional, online questionnaire design was employed with participants (N = 165) to examine the relationship between weekly average hours played and psychological wellbeing. Five previously reported motivators for playing were tested as mediating variables. In addition, exploratory analyses were conducted to determine the moderating effects of self-esteem and self-efficacy on 'escapist' gaming and psychological wellbeing. Results revealed a significant correlation with higher levels of play time associated with poorer psychological wellbeing. This relationship was partially mediated by 'escapist' motivation. Self-esteem was found to moderate the negative impact of 'escapist' gaming on psychological wellbeing. Research and the associated clinical implications are discussed.

Comparing the outcome of monitored anaesthesia care and local anaesthesia for carpal tunnel syndrome surgery by neurosurgeons.

INTRODUCTION: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy of the hand, up to 90% of all nerve compression syndromes. The disease is often treated with conservative measures or surgery. The senior author initially intended to treat his own neurosurgical patients concurrently diagnosed with carpal tunnel syndrome in 2014, subsequently, he began to pick up more referrals from the primary healthcare group over the years. This has led to the setup of a peripheral and spine clinic to act as a hub of referrals. OBJECTIVE: Department of Neurosurgery Sarawak aimed to evaluate the surgical outcome of carpal tunnel release done over five years. METHODS: The carpal tunnel surgeries were done under local anaesthesia (LA) given by neurosurgeons (Bupivacaine 0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC) was later introduced by our hospital neuroanaesthetist in the beginning of 2018 (Target-controlled infusion propofol and boluses of fentanyl). We looked into our first 17 cases and compared these to the two anaesthesia techniques (LA versus MAC + LA) in terms of patient's pain score based on visual analogue scale (VAS). RESULTS: Result showed MAC provided excellent pain control during and immediately after the surgery. None experienced anaesthesia complications. There was no difference in pain control at post-operation one month. Both techniques had equal good clinical outcome during patients' clinic follow up. CONCLUSION: Neurosurgeons provide alternative route for CTS patients to receive surgical treatment. Being a designated pain free hospital, anaesthetist collaboration in carpal tunnel surgery is an added value and improves patients overall experience and satisfaction.

Novel Divavirus (the family Betaflexiviridae) and Mitovirus (the family Narnaviridae) species identified in basil (Ocimum basilicum).

Transcriptome data obtained from a plant sample often contain a large number of reads that are derived from associated RNA virus genomes that were co-isolated during RNA preparation. These virus-derived reads can be assembled into a novel plant RNA genome sequence. Here, a basil (Ocimum basilicum) transcriptome dataset was analyzed to identify two new RNA viruses, which were named Ocimum basilicum RNA virus 1 (ObRV1) and Ocimum basilicum RNA virus 2 (ObRV2). A phylogenetic analysis of the ObRV1 RNA-dependent RNA polymerase (RdRp) motif indicated that ObRV1 is a novel species of the genus Divavirus of the family Betaflexiviridae. ObRV1 is the fourth divavirus species to be identified. The ObRV2 RdRp motif showed sequence similarity to viruses of the genus Mitovirus of the family Narnaviridae, which infect fungal mitochondria. Although most of the known mitoviruses do not produce a functional RdRp using the plant mitochondrial genetic code, the ObRV2 encodes a full-length RdRp using both the fungal and plant mitochondrial genetic codes.

Identification of a novel plant amalgavirus (Amalgavirus, Amalgaviridae) genome sequence in Cistus incanus.

Amalgaviridae is a family of double-stranded, monosegmented RNA viruses that are associated with plants, fungi, microsporidians, and animals. A sequence contig derived from the transcriptome of a eudicot, Cistus incanus (the family Cistaceae; commonly known as hoary rockrose), was identified as the genome sequence of a novel plant RNA virus and named Cistus incanus RNA virus 1 (CiRV1). Sequence comparison and phylogenetic analysis indicated that CiRV1 is a novel species of the genus Amalgavirus in the family Amalgaviridae. The CiRV1 genome contig has two overlapping open reading frames (ORFs). ORF1 encodes a putative replication factory matrix-like protein, while ORF2 encodes a RNA-dependent RNA polymerase (RdRp) domain. An ORF1+2 fusion protein, which functions in viral RNA replication, is produced by a +1 programmed ribosomal frameshifting (PRF) mechanism. A +1 PRF motif UUU_CGU, which matches the conserved amalgavirus +1 PRF consensus sequence UUU_CGN, was found at the boundary of CiRV1 ORF1 and ORF2. Comparison of 25 amalgavirus ORF1+2 fusion proteins revealed that only three different positions within a 13-amino acid segment were recurrently used at the boundary, possibly being selected so as not to interfere with correct folding and function of the fusion protein. CiRV1 is the first virus found to be associated with the Cistus species and may be useful for studying amalgaviruses.

Subcutaneous veins depth measurement using diffuse reflectance images.

Intravenous (IV) procedures are often difficult due to the poor visualization of subcutaneous veins. Because existing vein locators lack the ability to assess depth, and also because mis-punctures and poor vascular access remain problematic, we propose an imaging system that employs diffuse reflectance images at three isosbestic wavelengths to measure both the depth and thickness of subcutaneous veins. This paper describes the proposed system as well as proof-of-principle experimental demonstrations. We initially introduce the working principle and structure of the system. All measurements were based on the Monte Carlo (MC) method and accomplished by referring an optical density (OD) ratio to a multi-layer diffuse reflectance model. Results were all validated by comparative ultrasound measurements. Experimental trials included 11 volunteers who were subjected to both ultrasound measurements and the proposed optical process to validate the system's applicability. However, the unreliability of the "thickness" measurement of the vein may be due to the fact that the veins have collapsible walls - so excess pressure by the transducer will give a false thickness.

Evaluating an iPad app in measuring wound dimension: a pilot study.

OBJECTIVE: This pilot study tested the reliability, validity and sensitivity of an innovative prototype iPad app, WoundAide, developed to measure wound dimension (length, width and surface area) using image analysis. METHOD: A prospective evaluation was conducted comparing WoundAide (WA) with two gold standard instruments, Wound Zoom (WZ) and Visitrak (VT). The study was conducted in a tertiary hospital in Singapore. Patients were recruited after obtaining local ethics approval. RESULTS: We recruited six patients with 10 venous wounds. Images were captured by two researchers. Generally, 7/10 (70%) of the wounds had surface areas of less than 16cm². The intraclass correlation coefficient was greater than 0.95 for length, width and surface area for all measuring devices. The mean differences for length, width and surface area were not statistically significant. The average percentage of coefficient of variation for WA ranged from 3% to 33.3%, WZ 1.3% to 19.3%, and VT 2.1% to 43.4%. Length, width and surface area fell within the 95% limit of agreement. The capturing sensitivity was, on average, 75% for WA, 99.4% for VT, and 100% for WZ. CONCLUSION: WA has similar reliability and validity as WZ and VT. However, WA has the least sensitivity in image captures. Nonetheless, with enhancements made to its user-interface and system algorithm, this limitation can be addressed.

Evaluation of visual outcomes after toric intraocular lens implantation.

PURPOSE: To evaluate postoperative visual acuity, refractive status and rotational stability of toric intraocular lens (IOL) in correcting pre-existing corneal astigmatism. METHODS: A total of 69 patients with topographic corneal astigmatism of 1.0 Diopter (D) and above who underwent cataract surgery between June 2015 and December 2016 were included in this retrospective observational study. All preoperative toric IOL calculations were performed using immersion biometry. Appropriate formula to calculate toric IOL power was applied (SRK/T, Holladay 1 or Hoffer Q formula). All patients undergone similar uncomplicated phacoemulsification with implantation of AcrySoft IQ SN6AT toric IOL of different powers. Visual outcome, refractive status and axis of lens were evaluated at six weeks postoperatively. Ethical approval from the Ministry of Health Medical Research Ethics Committee was obtained prior to commencement of study. RESULTS: The mean refractive astigmatism decreased from 1.69 D ±1.10 (SD) to 0.81 D ± 0.40 (SD) at six weeks postoperatively. The mean postoperative spherical equivalent was at -0.37 D ±0.64 (SD). Mean LogMAR for uncorrected and corrected distance visual acuity in six weeks postoperative patients was at 0.29 ±0.16 (SD) and 0.12 ±0.12 (SD) respectively. Intraoperative to 6 weeks of postoperative comparison of IOL axis alignment showed low levels of rotation (mean 3.21 ±2.52 degrees). CONCLUSION: Cataract surgery with implantation of toric IOL was stable and effective in improving pre-existing regular corneal astigmatism.