THE ROLE OF DISTAL LOCKING IN INTRAMEDULLARY NAILS FOR HIP FRACTURE FIXATION: A REVIEW OF CURRENT LITERATURE.

Traditionally, it was believed that both proximal and distal locking are essential for achieving stability during intra-medullary fixation for extra-capsular hip fractures. However, recent literature has presented varying perspectives on the necessity of distal locking. Distal locking plays a significant role in managing hip fractures with uncertainties regarding longitudinal and rotational stability. This includes cases of comminuted intertrochanteric fractures with subtrochanteric extension, reverse oblique and high oblique fractures, broad medullary canals, comminution of the lateral wall, diaphyseal fractures, and large posteromedial fragments extending below the level of the lesser trochanter. In stable pertrochanteric fractures, with the lag screw passing through the lateral cortex of the distal fragment, may not require a distal locking screw. Distal locking has been associated with potential complications, including irritation of the fascia lata, prolonged operation time, increased radiation exposure, greater blood loss, implant loosening, secondary femoral stress fractures, and damage to the femoral artery. Thus, although distal locking is of doubtful significance in stable pertrochanteric fractures it is essential in unstable fracture patterns.

CURRENT CONCEPTS IN THE MANAGEMENT OF BOXER'S FRACTURE.

Fractures of the metacarpal particularly the 5th metacarpal is quite common among all hand fractures and has a high incidence in male adult population. Proper management of these fractures plays a key role in rehabilitation and early return to work thus reducing the economic burden. Treatment of these injuries depends on the type of injury: whether it is a closed/open fracture, degree of angulation at the fracture site and also mal-rotation and shortening of the finger. Non-operative management is suitable for fractures which are closed, non-displaced and without angulation or rotation. Open fractures, fractures with angulation and/or mal-rotation and fractures with neuro-vascular injury are more suitable for operative management. The acceptable angulation for conservative management for most studies is 70 degrees. Buddy strapping with a Futura splint provides good functional results. In fractures requiring operative intervention, K-wire fixation is a minimally invasive method of fixation, which in most cases has good functional results. Plate and screw fixation, however, is preferred for cases with significant comminution or multiple metacarpal fractures.

SAFE USE OF INTRA-OPERATIVE TOURNIQUETS IN A DISTRICT HOSPITAL IN THE UK-AN AUDIT STUDY IN ORTHOPAEDIC THEATRES AND REVIEW OF CURRENT LITERATURE.

The use of tourniquet is common in orthopaedic surgeries as it reduces blood loss, enhances visualization of the operating field, and leads to quicker procedures. However, the use of tourniquet has certain risks which can be avoided by following guidelines like British Orthopaedic Association Standards for Trauma (BOAST) guidelines for safe use of tourniquet. This audit study was done in a District general hospital to check the compliance of two trauma theatres with BOAST guidelines. The audit found that there was poor documentation of tourniquet details in the operation notes (10%). Regarding tourniquet time and pressure, the compliance in the two theatres was 95 % & 97.5 %. The recommendations of this audit were to use a template to improve documentation of tourniquet details in the operation notes and training of theatre staff on BOAST guidelines for safe use of tourniquet.

IMPORTANCE OF JOINT LINE RESTORATION IN TOTAL KNEE ARTHROPLASTY.

The restoration of the joint line is important for a good functional outcome after a Total Knee Arthroplasty(TKA). Knee joint biomechanics need to be restored as near normal as possible. Joint line elevation leads to anterior knee pain, decrease in range of motion, patella baja ,mid-flexion instability and impingement of patellar tendon. Joint line depression on the other hand leads to patella alta, risk of patellar subluxation and mid-flexion instability of the knee. Various studies have demonstrated various range of acceptable joint line variation but there is no clear acceptable range of joint line variation. More studies are required for establishing the acceptable range of joint line variation and standard practices should be established for arthroplasty surgeons for preventing variation of joint line.

Molecular characterisation of measles virus strains among refugees from Central African Republic in Cameroon in 2014.

Measles is a highly infectious human viral disease caused by measles virus (MeV). An estimated 114 900 measles deaths occurred worldwide in 2014. There are currently eight clades (A-H) comprised 24 MeV genotypes. We sought to characterise MeVs among Central African Republic (CAR) refugees during the 2014 measles epidemic in Cameroon. Samples were collected from children <15 years with suspected measles infections in two refugee camps in the east region of Cameroon. Viral RNA was extracted directly from urine samples. RNA detection of MeV RNA was performed with real-time reverse transcription polymerase chain reaction (PCR) to amplify a 634 bp nucleotide fragment of the N gene. The sequence of the PCR product was obtained to determine the genotype. MeV RNA was detected in 25 out of 30 samples from suspected cases, and among the 25 positive samples, MeV sequences were obtained from 20. The MeV strains characterised were all genotype B3. The MeV strains from genotype B3 found in this outbreak were more similar to those circulating in Northern Cameroon in 2010-2011 than to MeV strains circulating in the CAR in 2011. Surveillance system should be improved to focus on refugees for early detection of and response to outbreaks.

CD39 overexpression does not attenuate renal fibrosis in the unilateral ureteric obstructive model of chronic kidney disease.

Chronic kidney disease has multiple etiologies, but its single, hallmark lesion is renal fibrosis. CD39 is a key purinergic enzyme in the hydrolysis of ATP and increased CD39 activity on regulatory T cells (Treg) is protective in adriamycin-induced renal fibrosis. We examined the effect of overexpression of human CD39 on the development of renal fibrosis in the unilateral ureteric obstructive (UUO) model, a model widely used to study the molecular and cellular factors involved in renal fibrosis. Mice overexpressing human CD39 (CD39Tg) and their wild-type (WT) littermates were subjected to UUO; renal histology and messenger RNA (mRNA) levels of adenosine receptors and markers of renal fibrosis were examined up to 14 days after UUO. There were no differences between CD39Tg mice and WT mice in the development of renal fibrosis at days 3, 7, and 14 of UUO. Relative mRNA expression of the adenosine A2A receptor and endothelin-1 were higher in CD39Tg than WT mice at day 7 post UUO, but there were no differences in markers of fibrosis. We conclude that human CD39 overexpression does not attenuate the development of renal fibrosis in the UUO model. The lack of protection by CD39 overexpression in the UUO model is multifactorial due to the different effects of adenosinergic receptors on the development of renal fibrosis.

Whole-genome sequencing establishes persistence of biofilm-associated Pseudomonas aeruginosa detected from microbiological surveillance of gastrointestinal endoscopes.

BACKGROUND: An increased incidence of Pseudomonas aeruginosa in microbiological surveillance (MS) cultures from gastrointestinal endoscopes was detected between March 2020 and March 2023 in Tan Tock Seng Hospital Singapore. AIM: To describe the use of whole-genome sequencing (WGS) in this investigation. METHODS: WGS was performed for all P. aeruginosa isolates with pairwise comparison of isolates to assess for genomic linkage. Comprehensive review of reprocessing practices and environmental sampling was performed. FINDINGS: Twenty-two P. aeruginosa isolates were detected from endoscopic MS cultures. Fifteen (68%) isolates were available for WGS. Eighteen pairwise comparisons of isolates were made, of which 10 were found to be genomically linked. One endoscope had P. aeruginosa repeatedly cultured from subsequent MS that were genomically linked and persistent despite repeat endoscopic reprocessing, establishing the persistence of biofilm that could not be eradicated with routine reprocessing. All P. aeruginosa isolates cultured from other different endoscopes were genetically distinct. Investigation into reprocessing practices revealed the use of air/water valves connected to endoscopes during clinical use. Inspection of these valves revealed the presences of cracks and tears. All other environmental samples were negative. CONCLUSION: The WGS findings helped to deprioritize common source contamination and supported the hypothesis of biofilm build-up within endoscopes, leading to repeatedly positive MS cultures that were genomically linked. This was possibly related to incomplete reprocessing of the damaged air/water valves, resulting in biofilm build-up. All faulty valves were changed and subsequently cleaned separately with ultrasonic cleaning followed by sterilization which resolved this incident.

Population-specific recombination sites within the human MHC region.

Genetic rearrangement by recombination is one of the major driving forces for genome evolution, and recombination is known to occur in non-random, discreet recombination sites within the genome. Mapping of recombination sites has proved to be difficult, particularly, in the human MHC region that is complicated by both population variation and highly polymorphic HLA genes. To overcome these problems, HLA-typed individuals from three representative populations: Asian, European and African were used to generate phased HLA haplotypes. Extended haplotype homozygosity (EHH) plots constructed from the phased haplotype data revealed discreet EHH drops corresponding to recombination events and these signatures were observed to be different for each population. Surprisingly, the majority of recombination sites detected are unique to each population, rather than being common. Unique recombination sites account for 56.8% (21/37 of total sites) in the Asian cohort, 50.0% (15/30 sites) in Europeans and 63.2% (24/38 sites) in Africans. Validation carried out at a known sperm typing recombination site of 45 kb (HLA-F-telomeric) showed that EHH was an efficient method to narrow the recombination region to 826 bp, and this was further refined to 660 bp by resequencing. This approach significantly enhanced mapping of the genomic architecture within the human MHC, and will be useful in studies to identify disease risk genes.

Identification of a hidden outbreak due to the spread of a VIM-3-producing, extensive drug-resistant Pseudomonas aeruginosa (XDRPA) clone at a regional hospital in Taiwan.

A review of the annual prevalence of Pseudomonas aeruginosa at a regional hospital in Taiwan revealed a significant increase in the incidence of extensive drug-resistant P. aeruginosa (XDRPA) from 2∙1% in 2003 to 5∙8% in 2007. The first XDRPA isolate was recovered in 2001 from the emergency ward. The widespread dissemination of XDRPA isolates to more than 10 other wards was discovered the following year. Six pulsotypes of 67 XDRPA isolates from 2006 onwards were identified and 91% were a single strain, suggesting the existence of a hidden outbreak. Prior to the recognition of the outbreak, the majority of cases were not considered to be healthcare-associated infections until molecular evidence was provided. A cohort measure was launched by the infection control practitioners that effectively controlled the outbreak. Patients with XDRPA were mostly referred from neighbouring long-term care facilities, which may have been the reservoir of the XDRPA clone.

Do all the patients with gastric parietal cell antibodies have pernicious anemia?

OBJECTIVE: This study evaluated whether all the patients with serum gastric parietal cell antibody (GPCA) positivity had pernicious anemia (PA). MATERIALS AND METHODS: The blood hemoglobin (Hb), iron, and vitamin B12 concentrations, and mean corpuscular volume (MCV) in 124 GPCA-positive patients were measured and compared with the corresponding data in 124 age- and sex-matched healthy controls. PA was defined by World Health Organization (WHO) as having an Hb concentration < 13 g dl(-1) for men and < 12 g dl(-1) for women, an MCV ≥ 100 fl, and a serum vitamin B12 level < 200 pg ml(-1) . RESULTS: We found that 20, 25, and 20 GPCA-positive patients had deficiencies of Hb (men < 13 g dl(-1) , women < 12 g dl(-1) ), iron (<60 µg dl(-1) ), and vitamin B12 (<200 pg ml(-1) ), respectively. Moreover, 16 GPCA-positive patients had abnormally high MCV (≥ 100 fl). GPCA-positive patients had a significantly higher frequency of Hb, iron, or vitamin B12 deficiency and of abnormally high MCV (all P-values < 0.001) than healthy controls. However, only 12.9% of 124 GPCA-positive patients were diagnosed as having PA by the WHO definition. CONCLUSION: Only 12.9% of GPCA-positive patients are discovered to have PA by the WHO definition.

Contamination of the central medical air supply with water leading to mass ventilator failure.

Here, we present a case of mass ventilator failure due to contaminated medical air. Multiple ventilators failed routine tests, including almost all of the ventilators in our intensive care unit. A faulty air compressor had led to water contamination of our centre's supply of medical air. Water entered the pipeline supply of air and, hence the ventilators and anaesthetic machines. The disruption of the machines' proportional mixer valve resulted in unreliable delivery of fresh gas flow. This malfunction was discovered during routine pre-use checks, and backup ventilators were available to replace the faulty ventilators. A shortage of equipment was averted due to a serendipitous availability of ventilator stockpiles prepared for the COVID-19 pandemic. Ventilator shortages are commonly described in mass casualty and pandemic scenarios. While there are multiple strategies described in literature to augment and maximise equipment available for mechanical ventilation, stockpiling equipment remains an expensive but necessary component of disaster contingency planning.

Association of Oral Health with Frailty, Malnutrition Risk and Functional Decline in Hospitalized Older Adults: A Cross-Sectional Study.

BACKGROUND: Poor oral health is known to be associated with adverse outcomes, but the frequency and impact of poor oral health on older adults in the acute inpatient setting has been less well studied. OBJECTIVES: We examined the association between oral health, frailty, nutrition and functional decline in hospitalized older adults. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: We included data from 465 inpatients (mean age 79.2±8.3 years) admitted acutely to a tertiary hospital. METHODS: We evaluated oral health using the Revised Oral Assessment Guide (ROAG), frailty using the Clinical Frailty Scale (CFS), malnutrition risk using the Nutritional Screening Tool (NST) and functional status using a modified Katz Activities of Daily Living (ADL) scale. We examined cross-sectional associations of oral health with frailty, malnutrition risk and functional decline on admission, followed by multivariate logistic regression models evaluating the association between poor oral health and the aforementioned outcomes. RESULTS: 343 (73.8%), 100 (21.5%) and 22 (4.7%) were classified as low, moderate and high risk on the ROAG, respectively. Poorer oral health was associated with greater severity of frailty, functional decline on admission and malnutrition risk. Abnormalities in ROAG domains of voice changes, swallowing difficulty, xerostomia, lips and tongue appearance were more frequently present at greater severity of frailty. Poor oral health was associated with frailty [odds ratio (OR): 1.76, 95% confidence interval (CI) 1.05-2.97; P=0.034]; malnutrition risk [OR: 2.76, 95% CI 1.46-5.19, P=0.002] and functional decline [OR: 1.62, 95% CI 1.01-2.59, P=0.046]. CONCLUSIONS: Poor oral health is significantly associated with frailty, malnutrition risk and functional decline in older inpatients. Oral health evaluation, as part of a comprehensive geriatric assessment may be a target for interventions to improve outcomes. Further research including longitudinal outcomes and effectiveness of specific interventions targeted at oral health are warranted in older adults in the inpatient setting.

Singapore Clinical Practice Guidelines For Sarcopenia: Screening, Diagnosis, Management and Prevention.

OBJECTIVES: To present the local evidence and final recommendations of the Clinical Practice Guidelines workgroup convened by the Chapter of Geriatricians and the Society for Geriatric Medicine Singapore. The aim is to develop contextualized evidence-based recommendations that facilitate adoption of the Asian Working Group for Sarcopenia (AWGS) 2019 consensus into current practice in Singapore. METHODS: The workgroup drew upon the AWGS'2019 consensus, updated literature review of Singapore studies till 31 Dec 2020, and evidence from recent systematic reviews. From 40 local studies included for data extraction, we constructed evidence tables organized as: definition and epidemiology; diagnosis and evaluation; and treatment and intervention. Twenty recommendations - case-finding, diagnosis, treatment, prevention, research - were developed, and graded for strength and quality using the GRADE approach. Consensus from an expert panel(N=23) was achieved after two rounds of the modified Delphi process. RESULTS: The local prevalence of sarcopenia among community-dwelling older adults ranged from 13.6% to 25%. Most studies adopted the AWGS'2019 and AWGS'2014 criteria. Reported case finding tools include SARC-F, calf circumference (CC) and SARC-CalF. Gender-specific AWGS cut-offs for appendicular skeletal mass were used to define low muscle mass. Different protocols and dynamometers were used to assess handgrip strength, whilst gait speed and 5-times chair stand were commonly used to assess physical performance. RECOMMENDATIONS: We conditionally recommend a case-finding approach in at-risk older adults using validated case-finding tools. Screen-positive individuals should be assessed for 'possible sarcopenia' and underlying causes. For diagnosis, we conditionally recommend using the AWGS'2019 algorithm, and dual-energy X-ray absorptiometry when necessary to determine low lean mass for a confirmatory diagnosis of sarcopenia. For treatment, we strongly recommend resistance-based exercises and conditionally recommend a quality protein-rich diet/protein supplementation, with Vitamin D supplementation for insufficiency (<30 micrograms/L). For prevention, we recommend regular resistance-based physical activity and adequate protein intake (≥1.0g/kg bodyweight). We encourage more research to address local evidence gaps.

Myalgic encephalomyelitis: International Consensus Criteria.

The label 'chronic fatigue syndrome' (CFS) has persisted for many years because of the lack of knowledge of the aetiological agents and the disease process. In view of more recent research and clinical experience that strongly point to widespread inflammation and multisystemic neuropathology, it is more appropriate and correct to use the term 'myalgic encephalomyelitis' (ME) because it indicates an underlying pathophysiology. It is also consistent with the neurological classification of ME in the World Health Organization's International Classification of Diseases (ICD G93.3). Consequently, an International Consensus Panel consisting of clinicians, researchers, teaching faculty and an independent patient advocate was formed with the purpose of developing criteria based on current knowledge. Thirteen countries and a wide range of specialties were represented. Collectively, members have approximately 400 years of both clinical and teaching experience, authored hundreds of peer-reviewed publications, diagnosed or treated approximately 50 000 patients with ME, and several members coauthored previous criteria. The expertise and experience of the panel members as well as PubMed and other medical sources were utilized in a progression of suggestions/drafts/reviews/revisions. The authors, free of any sponsoring organization, achieved 100% consensus through a Delphi-type process. The scope of this paper is limited to criteria of ME and their application. Accordingly, the criteria reflect the complex symptomatology. Operational notes enhance clarity and specificity by providing guidance in the expression and interpretation of symptoms. Clinical and research application guidelines promote optimal recognition of ME by primary physicians and other healthcare providers, improve the consistency of diagnoses in adult and paediatric patients internationally and facilitate clearer identification of patients for research studies.

Modulation of serum gastric parietal cell antibody level by levamisole and vitamin B12 in oral lichen planus.

OBJECTIVES: The objective of this study was to test the efficacy of three different treatment modalities on the reduction of serum anti-gastric parietal cell autoantibody (GPCA) level in GPCA-positive oral lichen planus (OLP) patients. MATERIALS AND METHODS: Of 147 GPCA-positive OLP patients, 100 were treated with levamisole plus vitamin B12, 10 with vitamin B12 only and 37 with levamisole only. The serum GPCA levels in 147 OLP patients were measured at baseline and after treatment. RESULTS: Treatment with levamisole plus vitamin B12 for a period of 2-50 months and treatment with vitamin B12 only for a period of 4-44 months could effectively reduce the high serum GPCA level to undetectable level in 100 and 10 OLP patients, respectively. However, treatment with levamisole only for a period of 2-50 months could not modulate the high mean serum GPCA titer to a significantly lower level in 37 OLP patients. A 92% GPCA recurrence rate was found in 25 OLP patients receiving no further vitamin B12 treatment during the GPCA-negative remission period. CONCLUSION: For GPCA-positive OLP patients, treatment modality containing vitamin B12 can effectively reduce the high serum GPCA level to undetectable level. OLP patients with underlying autoimmune atrophic gastritis trait should receive a maintenance vitamin B12 treatment for life.

Determinants of fine manual dexterity in adolescents and young adults with Down's syndrome.

BACKGROUND: To date, numbers of studies have indicated the important role of fine manual dexterity in typical and special populations. However, the relevant studies in Down's syndrome (DS) population is still limited. The purpose of this study was to investigate the determinants of manual dexterity in adolescents and young adults with DS. METHODS: Thirty participants with DS (22 males, 8 females, aged 13-31) were screened by anthropometric variables (i.e. sex, chronological age, verbal intelligence, body mass index), levels of physical activity, and sleep disorders, and were administered the Purdue Pegboard Test and the Choice Reaction Time Test. Measures of correlation, t-test and multiple regression model were used for data analysis. RESULTS: It was indicated that sex and sleep-related disorders during the day explained 37.2% of the variance in the performance of the Purdue Pegboard Test. The additional of 9.7% can be explained the variance by adding reaction time test performance. Verbal intelligence had the negatively relation with the performance of non-Dominant Hand and Bimanual subtests of the Purdue Pegboard Test. CONCLUSION: This study suggested that sex, sleep disorder, and neuromotor function may be the important determinants of fine manual dexterity performance in adolescents and young adults with DS. In addition, the level of intelligence might also exert the effect on fine motor development in this population. In order to design effective interventions and optimize manual performance in individuals with DS, these possible determinants should be considered. Future research should be replicated with large sample size, different age groups, and validated measures of finger size, physical activity and sleep behaviors.

A 7-year surveillance for ESBL-producing Escherichia coli and Klebsiella pneumoniae at a university hospital in Taiwan: the increase of CTX-M-15 in the ICU.

To monitor the changing trend of extended-spectrum beta-lactamase (ESBL)-producing bacteria, a 7-year continuous study was launched in 2001 at the largest tertiary hospital in Taiwan. A significant increase over the study period was evident for ESBL-producing isolates of Escherichia coli (4.8-10.0%) and Klebsiella pneumoniae (15.0-23.4%). Molecular investigation conducted in three separate periods revealed the prevalent ESBL types and their genetic relatedness. CTX-M-producing isolates (73.8%) were more prevalent than SHV-type ESBLs (37.0%), the most frequent being CTX-M-14 (34.3%), CTX-M-3 (25.9%), and SHV-12 (25.7%). However, a marked increase of CTX-M-15-producing isolates from 2.1% in 2002 to 29.6% in 2007 was also noted. The increase of ESBL-producing isolates in both species may be mainly due to the horizontal transmission of resistance plasmids, while clonal expansion of some epidemic strains further added to the dispersion of ESBL-producing K. pneumoniae.

Development and validation of the Taiwan Children's Health Literacy Test.

BACKGROUND: Currently, health literacy (HL) worldwide is measured primarily among adults from a medical perspective. A children's HL test from a health promotion perspective is needed. This study develops the Taiwan Children's Health Literacy Test (TCHL) targeted at Taiwanese sixth-graders. METHODS: HL indicators were identified through interviews of sixth-grade teachers, primary caregivers, and sixth-graders. They were used to develop a 25-item online test, which was finalized after pretesting and administered to a stratified random sample of 671 students across 29 sixth-grade classes. RESULTS: The response rate was 87.2% (585 participants). Cronbach's α was 0.60-0.78 for the HL subtests and 0.79 for the overall HL test. Correlation coefficients among subtests ranged from 0.49 to 0.87. The average proportion correct was 0.80 for overall HL. In item response theory analysis, the difficulty level ranged from -2.77 to -0.40, while the degree of discrimination was 0.44-2.65. Item information peaked when the ability value was approximately -1.8. Furthermore, HL scores had a significant positive correlation with health behaviors. CONCLUSIONS: Overall, the test was found to be reliable and valid, with a low level of difficulty for basic HL ability. The present results can be used as a reference by government health education units to investigate national HL in children.

Clostridium innocuum is a vancomycin-resistant pathogen that may cause antibiotic-associated diarrhoea.

OBJECTIVES: Clostridium innocuum can cause extraintestinal infection in patients with underlying diseases. The role of C. innocuum in antibiotic-associated diarrhoea (AAD) remains unknown. METHODS: Clinical information of 103 patients from whom C. innocuum was isolated was reviewed. We carried out cellular and animal experiments to examine the pathogenic potential of C. innocuum in AAD. RESULTS: Eighty-eight per cent (91/103) of the 103 patients received antibiotics within 2 weeks of diarrhoea onset. Patients were further classified into two groups, severe colitis and diarrhoea, according to clinical severity level. The mortality rate was 13.6% (14/103) among the patients from whom C. innocuum was isolated. The lowest concentrations at which 90% of the isolates were inhibited for metronidazole and vancomycin were 0.5 and 16 mg/L, respectively. All isolates tested were susceptible to metronidazole but resistant to vancomycin. Nineteen randomly selected isolates (ten from severe colitis group, nine from diarrhoea group) were subjected to further in vitro cellular examinations. The level of cytotoxicity to Vero cells was significantly higher in isolates from the severe colitis group at both 24 and 48 hours after inoculation (24 and 48 hours, p 0.042 and 0.033, respectively). We observed apoptotic changes that subsequently led to cell death in C. innocuum-infected Vero cells. Tissue damages, necrotic changes and oedema were observed in the mouse ileal loop infected by C. innocuum. CONCLUSIONS: Vancomycin-resistant C. innocuum may play a potential role as a causative agent of AAD. The clinical manifestations of AAD caused by C. innocuum were diarrhoea or severe colitis, including pseudomembranous colitis.